Client Name *

First

Last

Email *

Patient Name *

Phone number at which owner can be reached today or tomorrow: *

Additional number

Before Procedure:

Would you like to be contacted before your pet goes in for the procedure *

Yes
No

Would you like to be contacted by text or phone call before the procedure? *

Text
Call
Either

If text, what number would you like to be texted at?

After procedure:

Would you like us to text you after the procedure, or would you prefer a call? *

Text
Call

Anesthetic and surgical procedure(s) to be performed: *

I, the undersigned owner or agent of the pet identified above, authorize the staff of Allied Emergency Veterinary Service to perform the above procedure(s). *

I have read and agree

Microchip: *There is an additional fee for this procedure* *

Yes
No
Already has one

Have you given your pets any medications or supplements in the past week? *

Yes, Presurgical Pack
Yes, Other medication(s), please specify below
No

Other medication(s), please specify and note last time given

When was the last time fed?

Any other concerns/allergies/procedures?

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. *

I have read and agree

I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the Allied Emergency Veterinary staff may or may not have my permission to proceed with life sustaining procedures. *

I give my permission [yes]
I do not give my permission [no]

While I accept that all procedures will be performed to the best of the abilities of the staff at Allied Emergency Veterinary Service, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree

Signature *

Date *

Surgery & Anesthesia Consent Form

Consent Form

Before Procedure:

After procedure:

COMPASSIONATE, HIGH QUALITY CARE

Two Convenient Locations!

Eau Claire, WI

Hudson, WI

Caring for your pets in Western Wisconsin, Eastern Minnesota, and Beyond.