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Informed Consent for Treatment and Surgery/Anesthesia Form

Please fill out this form as completely and accurately as possible.

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Informed Consent for Treatment and Surgery/Anesthesia Form

If you have any questions, please feel free to contact us at (775) 313-9232. We request that you be patient with our veterinary staff as we are working diligently to keep you and our team as safe as possible when bringing your pet to us.

Best Contact Phone Number for TODAY’s Visit: *

To evaluate and treat your pet at Fairgrounds Animal Hospital (FAH), the outlined procedures will be performed. This consent form ensures that you comprehend the risks, potential complications, our hospital policy, your financial responsibility, and resuscitation determination.

Read all of the information carefully and completely.

We encourage you to ask questions until you are satisfied with the answers, both medical and financial. If you do not feel comfortable with the procedure(s) outlined, you may consider an alternative course of action. Read each section and write your initials, indicating that you understand, in the spaces provided.

Procedure(s) *

I understand complications can occur despite the best medical/surgical care. *

I was informed of and discussed with the clinician/employee risks and potential complications associated with the proposed diagnostic and treatment plan(s). All of my questions have been answered to my satisfaction. *

Complications discussed include and are not limited to:

I have been informed/have discussed with the clinician/technician alternatives available to the proposed diagnostic and treatment procedure(s). I am satisfied with the answers provided to my questions. *

I am aware that and informed that anesthesia or sedation may be administered for diagnostic and/or treatment procedure(s). I understand there is risk of injury or death associated with anesthesia induction, maintenance, positioning and recovery. *

The risk is low for most pets and is greatest in brachycephalic or medically compromised patients. *

In the event my animal suffers cardiac or respiratory arrest, I authorize the attending clinician to: act in their best judgment

Act in their best judgment
Administer
DO NOT attempt to resuscitate (DNR)

I understand emergency resuscitation requires additional medications and treatments thus additional expense would be incurred for CPR/emergency treatment. *

I agree to pay this additional expense.
I do not agree to pay this additional expense.

I have been informed that the initial low/high cost estimate for the proposed diagnostic and treatment plan(s) is

(dollar amount varies w/ CPR level)

I agree to leave a deposit for the low end of the estimate now and pay the balance of treatment costs in full upon discharge of my animal. I understand that as the management of this case develops, additional diagnostics, treatments or courses of action may be required, the cost of which may exceed the high end of the original estimate. I will be contacted to authorize those changes and the additional charges associated with them, or to direct the clinician to discontinue treatment. *

I understand the cost associated with hospitalization of my animal, detailed in the agreed upon estimate. *

I understand that if my animal’s rabies vaccination status is unknown, expired or a current rabies vaccination certificate is not available for verification and the attending veterinarian deems it appropriate, a rabies vaccine will be administered to my animal. This policy reduces the risk of rabies transmission to our personnel if an animal bites/scratches during handling for diagnostics & treatment *

I am the owner or authorized agent of the above-named animal and at least 18 years of age. *

If my animal is diagnosed with internal or external parasites while in the hospital, treatment to prevent infestation of the hospital and other pets will be administered to my animal. I agree to pay for the treatments. *

I have read and fully understand the above information. Based on this information, I consent for Fairgrounds Animal Hospital to hospitalize and perform such services on the above-named animal. I agree to be responsible for the costs associated with all authorized charges. *

OWNER AUTHORIZATION SIGNATURE & FAH EMPLOYEE SIGNATURE:

Owner/Authorized Name: *

First

Last

Email *

Owner/Authorized Signature: *

Clear Signature

Date *

Informed Consent for Treatment and Surgery/Anesthesia Form

Informed Consent for Treatment and Surgery/Anesthesia Form

OWNER AUTHORIZATION SIGNATURE & FAH EMPLOYEE SIGNATURE:

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