Download consent to treatment and/or surgery

Elizabeth Danta Blount, DVM
Phone: 850.274.5710
Fax: 850.216.2973
www.athomevetintally.net
[email protected]
P.O. Box 14101
Tallahassee, FL 32317
CONSENT TO TREATMENT AND/OR SURGERY
Pet: _______________________________________
Date:__________________
1. I am the owner/agent for the patient and have authority to complete this consent.
2. I consent to and authorize the performance of the following procedure(s) and/or surgery.
_____________________________________________________________________________________
_____________________________________________________________________________________
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3. I understand that during the performance of the above procedure(s) or surgery unforeseen conditions may occur
that necessitate an extension of the above procedure(s) or different procedure(s) than those set forth above.
Therefore, I hereby consent to and authorize the performance of such procedure(s) or surgery as are necessary
and reasonable in the veterinarian’s professional judgment.
4. I also authorize the use of appropriate anesthetics, antibiotics, vaccines and pain medications as deemed
appropriate by the veterinarian and required by the policies of At Home Veterinary Care, LLC.
5. I have been advised of the nature of the procedure(s) or surgery and the risks involved. I realize that results
cannot be guaranteed and that the use of anesthetics, medications and/or surgery can result in complications,
including death.
6. I understand that I am financially responsible for all charges incurred in the treatment of my pet, and that in the
event of development of an illness or emergency that requires additional treatment, additional charges will
apply. I understand that payment in full is required at the time of my pet’s discharge, unless
arrangements are made in advance.
7. Pre-anesthetic bloodwork is recommended for all pets undergoing anesthesia/surgery, as it allows us to have
the best assessment of your pet’s overall health and assist us in selecting the safest treatment prcedures.
Specific Recommendations:
Pre-anesthesia mini screen ____________
Heartworm Test _____________ Feline Leukemia/AIDS/Heartworm Test____________
Complete Blood Profile______________
Complete Health Screen______________
Geriatric Health Profile_______________
I decline pre-anesthesia testing at this time. _____________
8. I understand that estimates of charges are only estimates and NOT A GUARANTEE of final charges.
Charges depend on treatment/services actually rendered. Reasonable attempts will be made, in advance,
to obtain approval for additional services. Contact Telephone Number for Today____________________
9. I have read and do understand this consent.
Witness to Signature
Signature of Owner/Agent
___________________________________
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