Authorization and Consent to Anesthesia for Surgery and/or Diagnostic/Therapeutic Procedures

Owner Name(Required)

I am the owner or agent for the above-named animal, I have the authority to execute this consent, and I agree to the terms outlined below.

Pet must be current on vaccines and intestinal parasite screening or they will be performed/administered at the owner's expense.

Pet must have recent laboratory tests on file, or have them performed today. These tests assist in tailoring specific anesthetic agents for your pet and increasing safety.

Pain management will be part of most surgeries/procedures and is not optional. The veterinarian will work with you to pick the safest and most convenient medications.

I hereby authorize the following procedure(s) to be performed by the admitting veterinarian or designated associate(s):
Laser Surgery
Declining the use of laser surgery may not be an option for some procedures.
If the veterinarian determines that further procedures are needed at this time:
If not available at that number, I wish:

Ancillary Procedures

Microchip ($57.50), Nail Trim (N/C), Ear Cleaning (N/C), Cold Laser Therapy ($27), Express Anal Glands ($28.90)


In an emergency, we will make all attempts to contact you at the listed emergency number. However, I authorize the clinic staff to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communicating with me. I understand that I assume all financial responsibility for all routine and emergency services rendered.

Emergency Preference:(Required)


I hereby authorize the clinic to perform such diagnostic, therapeutic, and surgical procedures as described above. The nature of such services has been described to me to my satisfaction, and I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure.

This field is for validation purposes and should be left unchanged.