Larchmont Village Vet - Surgery Consent Form

I, the undersigned, certify that I am the owner of the animal(s) presented for care, or an authorized agent acting on the owner’s behalf. I authorize the doctor on duty and assistants to perform the prescribed procedure(s) including administration of sedatives and/or anesthetics, as well as any necessary and appropriate medical, surgical, nursing, diagnostic, and/or emergency care for my pet. I have been advised as to the nature of the procedure and the potential risks. I also understand that no guarantee of successful treatment can be made.

I understand that Larchmont Village Vet is not a 24 hour hospital. Should an overnight stay be necessary, direct observation will not be available. If my pet needs observation we recommend transfer to a 24 hour emergency hospital.

In case of an emergency and/or prior to additional procedures, you will be contacted by telephone. The phone number(s) where you can be reached TODAY is/are:

Phone Number 1:*

Please enter a valid phone number.Format: (000) 000-0000.

Phone Number 2:

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Authorization for Life-Saving Treatments

In the event of a catastrophic emergency, please select what life-saving measures you would like performed. (please select one option below)*

CPR If my pet's heart or breathing stops, I authorize CPR, including chest compressions, emergency medications, intubation, oxygen support, and additional treatment based on doctor discretion.Do Not Resuscitate (DNR) If my pet's heart or breathing stops, I do not want CPR performed. I understand this means my pet will pass away naturally.

Owner Authorization & Consent

The nature of the procedure and the potential risks have been explained to me and I understand the procedure(s) to be performed. I understand that some risks always exist with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any and all my questions have been answered to my satisfaction. *

Initial

I understand that during these procedures great care is taken to ensure my pet’s health, but unforeseeable conditions may occur that necessitate an extension or variance in the procedure(s) defined above. I authorize Larchmont Village Vet to perform any additional diagnostic, treatment or surgical procedure(s) deemed necessary for medical or surgical complications or any unforeseeable circumstances. I accept responsibility for any result in additional charges. *

Initial

While Larchmont Village Vet provides the highest quality of anesthesia monitoring and surgical services, I understand the risks and understand that the veterinarians and hospital team will do everything possible to minimize any risks. I will not hold Larchmont Village Vet, the veterinarians, or any team member liable for any complications that may arise. No warranty or guarantee has been stated or implied to me as to the results or cure afforded by these treatments or procedures.*

Initial

I understand that I am assuming full financial responsibility for all services rendered. *

Initial

Owner Authorization & Consent

  Initial*

   Initial*

  Initial*

Initial*

Authorized Additional Services — Check all that you authorize.*

Nail trim (complimentary)Microchip (additional cost)Removal of retained deciduous (baby) teeth (additional cost)Other

Owner/Authorized Agent Signature:*

Sign above

Printed Name:*

First NameLast Name

Date*

Date