Consent Form in Selma, NC | For Pet's Sake Animal Hospital

Date*

Name of Pet*

Breed

Sex

Male
Female

Spayed/Neutered?

Yes
No

I hereby authorize For Pet's Sake Animal Hospital to perform the following procedure(s) to the pet(s) described above

Has your pet been held off food for 10-12 hours?

Yes
No

Has your pet been acting normally at home? IE - normal appetite, normal activity, etc?

Yes
No

If no, what problems is your pet having?

Is your pet on any medications?

Heartworm prevention
Flea prevention
Over-the-counter meds
Prescription meds
Other meds

Please list medications and when last dose was given

Has your pet ever had a seizure?

Yes
No

Would you like a microchip implanted in your pet while anesthetized?

Yes
No

Is there anything else we should know about your pet?

I am the legal guardian of agent of the above mentioned animal. I understand that all procedures, surgeries, sedation and anesthesias involve some minimal risk to my pet. For Pet's Sake Animal Hospital is dedicated to the highest level of care during such procedures. However, in the event that complications develop, Pet's Sake Animal Hospital, its agents, staff and employees will not be help liable for responsible in any manner for complications occurring during such procedures or services. I acknowledge no guarantee or assurance has been made as to the results that may be obtained. I hereby assume all risk(s) associated with the performance of the above procedure(s).

In the events of complications that require emergency treatment do you wish your pet to receive emergency treatment with medications and CPR for resuscitation?

Yes
No

Signature of owner or agent

Phone # where I can be reached at today