Surgical Consent Form Client's Name First Last Pet's NameSurgical ProcedureSpayCastrationDental Scaling/Polishing/ExtractionExtractions are additional. Do we have permission to extract diseased teeth?YesNoWould you like a microchip implanted for identification during the procedure?YesNoWould you like your pet’s teeth cleaned during the procedure if time allots? Additional fees applyYesNoDo we have permission to extract disease teeth?YesNoYour pet must be fasted. No food after 8pm the night before and no water after midnightYesNoMedical History: Check all that apply Heart Condition Bleeding disorder Respiratory disorder Recent Estrus (Heat) On Heartworm Prevention (If not will need Heartworm test) Medication reactions Diabetes Cushings, Thyroid, Liver disease or kidney disease OtherMedication reactionsOtherCONSENT FOR SURGICAL ADMISSION TO HOSPITALI am the owner or agent for the owner of the animal(s) described on this form and have the authority to execute this consent. I request that the veterinarians, agents and employees of Colonial Animal Hospital perform the services which are necessary to the examination, medication and treatment of the animals specifically described and identified on this form. I authorize the veterinarians on duty (and the assistants they designate) to examine the animal(s) and to administer medical treatment or emergency surgical treatment which is considered therapeutically and/or diagnostically necessary on the basis of the findings during the course of the examination. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment. I further understand that any animal found to be infected with either external or internal parasites will be treated for same at my expense. I understand that the treatment of the patient will be conducted with due care and in accordance with the prevailing standards of competency in Veterinary Medicine. I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by the veterinarians, agent or employees of Colonial Animal Hospital. I assume financial responsibility for all charges incurred to the patient for services rendered and understand that full payment is required upon discharge. In case of non-payment, I am aware that Colonial Animal Hospital will charge the cost of collecting the debt on the amount owed for services. This includes the collections company’s charges, attorney’s fees and interest of 1.5 % per month (18% annum). I understand that a written estimate of charges is available within reasonable time at my request. I also consent to the release of medical information.SignatureDate Date Format: MM slash DD slash YYYY Daytime contact phoneHome phoneMust be available at all timesPlease allow 15 minutes upon check in.