Pet Information

Pet's Name *

Contact Information

Owner's Name *

First

Last

Email *

Phone *

Additional Phone

Do you agree to receive text messages from Justin Animal Hospital? *

I agree

By checking this box, you consent to receive informational and/or promotional text messages from Justin Animal Hospital at the number provided, including messages sent by the autodialer. Consent is not a condition of purchase. Message & data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. Privacy Policy.

Secondary Contact: *

First

Last

* This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

Secondary Contact Phone *

Today's procedure is: (example: lump removal, exam, etc.) *

Contact there Animal

Additional Services Desired While Patient Is Sedated

Please select any/all that you would like us to provide while your pet is sedated

Please specify where the lumps are located: *

Please specify the additional service(s) you'd like provided to your pet: *

Authorization

I authorize anesthesia/sedation for my pet. The nature and risks of this procedure have been explained to me. I understand some risks always exist with anesthesia and/or sedation, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any questions have been answered to my satisfaction. *

I have read, understand, and authorize

I authorize Justin Animal Hospital to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical complications or otherwise unforseen circumstances. I understand there are rare complications associated with any anesthetic procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks and understand the veterinarians and hospital staff will try to minimize such risks. I will not hold Justin Animal Hospital, the veterinarians, or any staff member liable for any complications that may arise. *

I have read, understand, and authorize

Payment due upon services rendered. *

I have read, understand, and agree.

I HAVE READ AND FULLY UNDERSTAND THIS ANESTHESIA CONSENT FORM *

Yes

Signature of Responsible Party *

Clear Signature

Today's Date *

Anesthesia, Surgery, Sedation Consent Form

Pet Information

Contact Information

Additional Services Desired While Patient Is Sedated

Authorization

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