Surgery Consent Form | Kenwood Animal Hospital in Bethesda, MD

Name(Required)

First Last

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pet Name(Required)

Sex(Required)

Male

Female

I am the owner or agent of the pet described above, and have the authority to execute this consent.

I authorize the personnel of Kenwood Animal Hospital to perform the treatment/procedure(s) described below. I have been informed of the reasons for the treatment/procedure(s), along with the expected benefits and risks involved.

I understand that there are certain risks to anesthesia that could involve serious bodily injury or death and that these risks are present in any procedure that requires a general or intravenous anesthetic. I consent to the use of anesthesia.

I understand that unforeseen conditions and abnormalities may be revealed during this procedure which may not have been apparent hitherto, and therefore may not have been included as part of my pet’s procedural estimate.

Please review and initial one of the options below. We recommend that you discuss these options with your veterinarian and/or the surgeon performing today’s procedure.

Please enter the name of the procedure you are electing:(Required)

Treatment Consent

Treat as needed during the procedure, according to the necessity and as advisable in the professional judgement of the veterinarian

I pre-authorize treatment as needed during the procedure, without contacting me first, up to the amount indicated below.

I do not pre-authorize any procedure(s) in addition to the original estimate. Please contact me prior to additional procedure(s). I understand that if I am unreachable, the additional procedure(s) will not be performed and my pet may need to be rescheduled for a second anesthetic procedure.

If you indicated above that you pre-authorize treatment as needed, please indicate the dollar amount we are authorized up to:

Please initial below to indicate you HAVE RECEIVED AN ESTIMATE FOR TODAY'S PROCEDURE.

I understand the benefits of microchipping.

Would you like your pet to be microchipped?(Required)

I accept

I decline

I understand that Kenwood Animal Hospital is not staffed 24 hours a day, and my pet will not have overnight medical supervision.

I have read and understood this consent form. I realize that the results of this procedure cannot be guaranteed. I understand that estimates of costs are a best effort to predict costs surrounding this procedure, but cannot be provided with complete accuracy and/or detail. I consent to the proposed treatment/procedure(s) described above.

Signature(Required)

Date(Required)

Contact Number for Today(Required)

Please verify if your contact number is a cell phone or a home phone.(Required)

Yes

Secondary Phone Number

Please verify if your secondary number is a cell phone or a home phone.

Yes

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