Surgery Consent Form

Owner's Contact Information

Patient's Contact Information

I am the owner/agent of the above described animal and have authority to execute consent for the surgical/medical procedure above.

With full understanding of the above, the undersigned owner/agent authorizes Dr. Colin Scruton and staff to perform under any anaesthetic deemed advisable, said operation/procedure. I understand that further procedures may be therapeutically necessary based on findings during the operation/ procedure, I consent to those procedures, their additional cost, and any unexpected lifesaving emergency care deemed necessary by the attending veterinarian.

I understand that risks and potential complications exist with anaesthesia and surgery. These include, but are not limited to abnormal reaction to anaesthetic agents, self-inflicted injury during anaesthesia recovery (i.e., fractured legs, head trauma), muscle and nerve damage, dehiscence of incision, colic, post-operative infection, equipment failure, and death.

Surgically removed tissues will be processed according to normal hospital policy, to establish an accurate diagnosis.

I acknowledge and understand that the procedure, its consequences, and subsequent risks have been explained to me, and I have addressed any questions or concerns I may have. I also realize that the results cannot be guaranteed.

As agent or owner, I understand that the owner is financially responsible to Equerry for all applicable charges relating to this animal. It is the owner’s obligation to inquire about all costs of patient care and to maintain status of the financial obligation to Equerry. 50% of the estimate is due at the time of hospitalization and prior to commencement of surgery. Payment of services is due in full at dismissal. If payment is not received in full at the time of dismissal a $25.00 service fee will be administered. Late payment charges of 2% per month and other penalties specified may be assessed.