Pittsboro Animal Hospital
919-542-5712

919-542-5750 (fax)

info@pittsboroanimalhospital.com
1065 East Street, Pittsboro, NC 27312

Surgery Consent Form
Surgery Consent Form

Tip: You can provide a brief description of your form. Also, you may want to let your customers know what happens after they submit the form. For example, upon form submission, they would be added to your contact list.

Owner Information   
First Name: *
Last Name: *
Cell Number *
Alternate Phone:
Would you prefer text or call?:
   
 Pet Information  
Pet's Name: *
Procedure(s) to be done: *
When did your pet last eat?: *
 Is your pet experiencing any of the following symptoms?
Check all that apply or type "none":
*
 
   CoughingSneezing
Limping
Vomiting
DiarrheaWeakness
Excessive drinking
Excessive urinationStraining
Decreased appetitePain
   
 This section for dogs only  
My dog is current on monthly heartworm prevention:
If your answered "no" to the above question we recommend having a heartworm test performed as a heartwrom positive dog has an increased risk under anesthesia  
I authorize Pittsboro Animal Hospital to perform a heartworm test at an increased cost:
   
Any other concerns?:
   
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 procedure(s) listed above and on the attached estimate, including administration of pain relief medications, sedatives and/or anesthetics, as well as any necessary and appropriate medical, radiological, surgical, nursing,diagnostic, and/or emergency care for the animal. I have been advised as to the nature of the procedures and the potential risks. I also understand that no guarantee of successful treatment can be made. I also understand that the estimate is just an estimate and other costs may arise related to the care of my pet and take responsibility for such charges. I have read and understand the reasons for and the risks of the above and attached authorized procedure(s), and assume full financial responsibility for all charges and services incurred to the described animal. By typing my name in the box I an signing this Surgical Consent Form.: * Type Full Name Here
 Date: