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Special Surgery Consent Form
Special Surgery Consent Form
Date Format: MM slash DD slash YYYY
Your pet's name
I hereby consent and authorize the medical staff at the People for Animals (PFA) to receive, prescribe for, treat and operate on the pet(s) named above. I represent that I am the owner of the pet(s) in question or that I am authorized by the owner to consent to this treatment. I will indemnify and hold PFA harmless from claims by the owner in the event that this representation is not true. To my knowledge, my pet has not bitten or otherwise injured anyone within the last ten days. I understand that there are risks inherent with anesthesia and surgery, and I accept that death or prolonged illness may result, especially if my pet is in compromised health whether known or unknown prior to surgery. Although all reasonable precautions will be taken, I assume all risks and I release People for Animals, Inc. from all liability. I understand that anatomical characteristics associated with my pet’s breed may place him/her at increased risk for death or complications during or following surgery, especially brachycephalic breeds including but not limited to French Bulldog, Pug, Pekingese, Shih Tzu, Boston Terrier, Mastiff, and Persian. I also agree that I am liable for any additional medical costs which result from my failure to disclose any prior medical condition of my pet. I understand that if my pet acts in a manner that poses a safety risk to the staff at PFA, my pet may be sedated prior to receiving an examination. If a medical/surgical emergency arises, PFA will use the emergency telephone number that is provided below to contact me. In the event that I cannot be reached in a timely manner, I authorize PFA to transport my pet to an emergency facility for treatment. I assume all financial responsibility for any additional medical or emergency treatment that may be required. I understand that if my pet must receive any additional medication or other treatment that there will be an additional charge. If I am late picking up my animal, causing the clinic to remain open past the posted closing time, I will be charged a fee of $25. I understand that my pet will be left unattended after the clinic closes anytime the animal is kept at PFA’s clinic overnight. If I do not pick up my pet at the designated time of discharge, I will be charged a daily fee of $25 until the animal is claimed. If the animal is not claimed after 10 days, it will become the property of People for Animals, Inc. to do with as it sees fit. I will be responsible for paying all costs incurred by People for Animals, Inc. that are associated with my pet’s care and boarding at all times. I understand that PFA recommends the purchase of an Elizabethan collar for the purpose of preventing my pet from chewing at the incision area. If I choose not to use an Elizabethan collar, I am responsible for any emergency care that may be needed. I understand that my pet will receive a tattoo on the abdomen as a lasting indication that it has been altered. I understand that pregnancy presents an increased risk of death or complications during or following surgery. I further understand that any pregnancy will be terminated at the time of spaying. Special Circumstances: I understand that the veterinarians at People For Animals have recommended that my pet’s surgery be performed at a full service veterinary hospital and NOT at PFA’s high volume clinic based on my pet’s health history. I understand that while my pet will be attended at all times while under anesthesia PFA does not utilize intraoperative mechanical monitoring of cardiopulmonary activity and other vital signs that would be used in a full service veterinary hospital setting. I further understand and accept that there may be health consequences related to my pet’s prior medical issues that may not be known and may constitute an increased risk of death or other bad outcome of surgery and anesthesia. Knowing all this, I have requested that my pet have surgery at PFA against medical advice and I therefore release PFA, their employees and veterinarians from responsibility. I have read the foregoing, and I understand and agree to its contents.
Have you read and agree to consent?
I have read the special surgery consent form, and I understand and agree to its contents.