Client Name Chart Pet's Name Sex Age: Breed: Color: Procedure: I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the animal described above. I authorize the doctor on duty and assistants to perform the procedures listed above and on the attached estimate. Such procedures will include administration of pain relief medications, sedatives or anesthetics, as well as any necessary and appropriate medical, radiological, surgical, nursing, diagnostics, and/or emergency care for the animal. I have been advised as to the nature of the procedures and potential risks. These risks include, but are not limited to: Infection Anesthetic complications- Reaction to medication, Death Seroma/Hematoma Formation Tracheal Irritation Surgical complications which affect the outcome of the procedure Dehiscence Should any of these complications arise, I recognize that the hospital will not be at fault/responsible for the cost of additional treatment/management.the procedure l understand that no guarantee of successful treatment can be made. Client SignatureDate MM slash DD slash YYYY By checking this box, I Do wish for CPR to be performed if necessary on my pet. I understand that life saving measures may be an additional charge. By checking this box, I elect for my pet NOT to be resuscitated in the chance that it is necessary. This choice is a DNR (Do not resuscitate). Client SignaturePrint Name Date MM slash DD slash YYYY Please provide the best phone numbers to reach you at in case of emergencies and for updates regarding your pet.Primary numberSecondary number
