Client Details:

Name *

First

Last

Address

Address Line 1

City

State

Zip Code

Home Phone

Mobile Phone

Email *

Animal Details:

Name of Animal *

Species *

Breed *

DOB *

Sex *

Weight *

What is the procedure your pet is having? *

Has your pet eaten after 8pm last night? *

Yes
No

Has your pet had any medication recently? *

Yes
No

If anesthesia/sedation is required, I understand that there are risks involved and that in the event of an emergency, the hospital will take all necessary actions to control the problem and will notify me as soon as possible. *

I have read and understand.

I understand that Elon Animal Hospital takes all necessary precautions to ensure my pet's safety and uses the safest anesthetic protocols available for my pet. I understand that, despite these interventions, there are risks involved in anesthesia/sedation including cardiac arrest and death. In the event that my pet experiences cardiac arrest while under the care of Elon Animal Hospital, my wishes are as follows: *

I hereby authorize Elon Animal Hospital to initiate cardiopulmonary resuscitation (CPR). I understand that additional costs up to $500 may be incurred during CPR and that these costs are not included in the estimate provided for the original procedure.
I hereby declare that I do not wish for Elon Animal Hospital to initiate attempts to resuscitate my pet (DNR). I understand that my pet is unlikely to survive cardiac arrest without intervention.

I have been provided an estimate for this procedure *

Yes
No

I fully understand that this is an estimate only. Elon Animal Hospital makes every effort to remain within the estimate given. *

I have read and understand.

I agree to meet the costs of all treatment at the time of discharge. I understand the risks and complications of these procedures, which have been explained to me by the Veterinarian. *

I have read and understand.

All accounts are payable at the time of consultation unless a prior arrangement has been made.

Signature *

(OWNER or AGENT)

Today's Date *

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Procedure Consent Form

Client Details:

Animal Details:

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