Surgical Authorization

Owner's Name*

First Last

Date*

Primary Contact #*

Alternate Contact #

Address*

Street Address Address Line 2 City State ZIP Code

Pet's Name*

Breed*

Age (in years or months)

Pet History

Are Vaccinations Current?*

Yes
No

Is your dog on heartworm prevention?*

Yes
No

Is your pet currently on flea/tick prevention?*

Yes
No

Any vomiting, coughing, or diarrhea?*

Yes
No

Did your pet eat this morning?*

Yes
No

Is your pet allergic to any drugs?*

Yes
No

Has your pet had any illness or injury within 30 days?*

Yes
No

Today's Procedure

What is your pet coming in for today?*

Additional Services For Your Pet

While your pet is under anesthesia we can provide additional care with the following:

HomeAgain is safe, simple & life long form of ID designed to quickly ID lost pets. Permanent ID comes from a tiny microchip (the size of a grain of rice) that's injected under the skin. $35 for implanting the chip and $19.99 for the activation. (Total cost = $54.99)*

Yes
No

Extract Puppy Teeth ($5 Each)*

Yes
No

Express Anal Glands*

Yes
No

Ear Cleaning/Medicating*

Yes
No

Nail Trimming*

Yes
No

Is there anything else you would like the doctor to address while your pet is with us?*

Yes
No

*additional charges may apply

Please Explain*

Other Releases*

I have read the below agreeing to all stated

As your pet is to be admitted, rest assured that advances in anesthesia & surgery have made routine procedures relatively safe with a low rate of complications. Nonetheless, occasional problems can arise. Jackson Veterinary Hospital will use all reasonable precaution against injury, escape, or death of my pet. I, the owner, understand that all anesthesia involves some risk to any pet. Jackson Veterinary Hospital will not be held liable or responsible under any circumstances. I the pet owner understand & assume all risks associated with the above procedure.

I authorize Jackson Veterinary Hospital to provide necessary medical or surgical procedures for the above animal. I am of legal age & assume all financial responsibility for such services as provided by the hospital & know that payment is due upon release of the animal.

Surgical Consent*

I have and read and agree with the statement below.

I hereby authorize Jackson Veterinary Hospital to perform the procedure listed on the estimate and to use general anesthesia. I acknowledge that I am the owner/appointed caregiver of the animal named above. I understand that any procedure may pose a risk to my pet, regardless of health and previous screening status. In the event of unforeseen compilations, I give permission for the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. As the owner or appointed care giver of the animal named above I understand that by checking this box, I agree to pay for all charges +/-15% of the fees shown on the estimate given and will pay the balance in full upon discharge of my pet. The procedure and relevant costs have been fully explained to me to my satisfaction.

Please read and consent to one of the following:*

If unexpected complications arise and I cannot be reached at my contact number, the Doctor may exercise his/her professional judgment and proceed accordingly until I am reached. I want extreme measures to be taken to save the life of my pet. I understand and agree that extreme measures can be costly and do hereby agree to pay those charges.
If unexpected complications arise and I cannot be reached at my contact number, do nothing until I am reached. I do not wish to have critical care treatment provided until have spoken with the doctor and have been provided with a detailed estimate. I understand this may delay critical care that may be necessary to save the life of my pet. I understand my pet may die without immediate critical care and I take responsibility for delaying care. In making this decision, the doctors and staff at Jackson Veterinary Hospital will not be held liable or responsible in any matter whatsoever. I have read this statement and am over the age of eighteen.
If unexpected complications arise and I cannot be reached at my contact number, perform necessary lifesaving procedures immediately, but delay any further procedures until am reached.

Owner/Appointed Caregiver Name*

First Last

Date*

Contact Us

Surgical Authorization