Hospitalization / Procedure Informed Consent Form

Patient & Owner Details

Fields marked with * are required.

Legal Owner Name *

First *

Last *

Patient Name *

Procedure(s) *

Last Meal Time *

Last Drink Time *

Best number to reach you at today *

Secondary Number

Other Medications *

Consent to Treat

Please read and check the following boxes of each statement in the space provided

I, the undersigned, owner or responsible party of the admitted patient, hereby authorize the Doctors of Edmonton West Animal Hospital & Spay/Neuter Centre (and whomever they may designate as assistants) to administer such treatments as necessary, and to perform surgical procedure.*

I understand that in cases where further, unforseen work is required and is of non-emergency nature (additional diagnostics, changes to treatment plans, etc.), every attempt will be made by the veterinarians/staff to contact the owner by phone to discuss the case. I also understand, if contact cannot be made in a timely manner, no additional work will be performed until informed verbal or written consent can be obtained. Once contacted and if I verbally agreed for recommended procedure, I grant authority for the purpose of remedying conditions that are found.*

Since general anesthesia or sedation is required in the above-mentioned procedures, I understand and accept that there are always inherent surgical and/or anesthetic complication risks, including death of the patient.*

Sedation & Anesthesia Options

If your pet requires sedation or anesthesia, please read and check off the box for the following statements. In order to minimize the risks associated with anesthesia / sedation, we recommend the following for every patient having a surgical procedure requiring sedation / anesthesia. I have marked off the boxes below to authorize the corresponding items.

Pre-anesthetic blood work ($120)IV Fluids / drip ($60)and / or IV catheter ($30)I do not authorize any above optional items and accept the inherent associated risks.

Overnight Hospitalization

If your pet requires overnight hospitalization, please select the appropriate statement below. *

I understand and accept that there is no overnight staff on duty after the hospital closes, and that my pet will be attended to the following morning.I prefer to take my pet to a 24-hour emergency/speciality clinic for overnight monitoring.

Authorization

I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment, and that the above procedure has been explained to my satisfaction. I also certify that no guarantee or assurance has been made regarding the results that may be obtained. I acknowledge that any post-surgical or post-anesthetic complications may require additional veterinary care or medications. Further, I assume full financial responsibility for all charges incurred to this patient.*

Signature *

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Verify you are human *