Pet Information
Pet's Name
(Required)
Contact Information
Owner's Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Additional Phone
Secondary Contact
(Required)
First
Last
* This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.
Secondary Contact Phone
(Required)
Today's procedure is: (example: lump removal, exam, etc.)
(Required)
Additional Services Desired While Patient Is Sedated
Please select any/all that you would like us to provide while your pet is sedated
Implant Microchip
Vaccination
FeLV/ FIV Test (Cats only)
Nail Trim (Complimentary)
Heartworm Test
Other (specify below)
Please specify the additional service(s) you'd like provided to your pet
(Required)
Additional Comments/ Concerns
Authorization
I authorize anesthesia/sedation for my pet. The nature and risks of this procedure have been explained to me. I understand some risks always exist with anesthesia and/or sedation, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure are initiated. My signature on this consent form indicates that any questions have been answered to my satisfaction.
(Required)
I have read, understand, and authorize
I authorize Falcon Family Vet to perform any additional diagnostic, treatment, or surgical procedure deemed necessary for medical complications or otherwise unforseen circumstances. I understand there are rare complications associated with any anesthetic procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks and understand the veterinarians and hospital staff will try to minimize such risks. I will not hold Falcon Family Vet, the veterinarians, or any staff member liable for any complications that may arise.
(Required)
I have read, understand, and authorize
Payment due upon services rendered.
(Required)
I have read, understand, and agree
Signature of Responsible Party
(Required)
Date
MM slash DD slash YYYY
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