Informed Consent for Medical Procedures, Anesthesia, and/or Surgery
Client’s Name____________________________________ Pet’s Name_____________________________
Medical treatments and/or procedure(s) to be preformed _________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I, the undersigned owner or agent of the owner of the pet identified above, authorize the veterinarian(s) at
Greenleaf Animal Hospital to perform the above procedure(s). I understand that some risks always exist
with drug therapy and medical treatments and I have been encouraged to discuss any concerns I have about
those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this
form indicates that any questions I have regarding the following issues have been answered to my
satisfaction:
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The reasonable medical treatment options for my pet
How fully my pet will recover and how long it will take
The most common and most serious side-effects
The length and type of follow-up care and home care required
The estimate of the fees for all services
While I accept that all procedures will be performed to the best of the abilities of the staff at the hospital, I
understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree
to assume financial responsibility and provide payment via cash or credit card at the time my pet is
discharged from the hospital. Should unexpected life-saving emergency care be required and the hospital
staff is unable to reach me, the staff____ does not have____ (check one) my permission to provide such
treatment and I agree to pay such services and understand that those fees are not included in my estimate.
I understand that during the performance of medical, surgical, or anesthetic procedures, unforeseen
conditions may be revealed and necessitate more extensive, costly, or different procedures then originally
planned. If staff at this veterinary practice are unable to reach me, I hereby consent to and authorize the
performance of such procedures as are necessary and desirable in the professional judgment of the
attending veterinarian.
I have read and fully understand the terms and conditions set forth above.
_____________________________________________
___________________
Signature of Owner or Agent
Date
_____________________________________________
___________________
Signature of Parent or Legal Guardian
(If owner or agent is less than 18 years of age)
Date
I can be reached at the following numbers (please indicate the best number to reach you at):
______________________ ______________________
______________________
Home
Business
Cell
______________________________________________________
E-mail
Best method to contact you: Call ( ) Email ( ) Text ( )
PLEASE read the following and initial accept or decline.
If you have any questions or are unsure of anything PLEASE ASK.
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Pre Anesthetic blood testing: Like you, our greatest concern is the well being of your pet. We
will perform a full physical examination on your pet before placing it under anesthesia. However,
some conditions, including disorders of the liver, kidneys, and blood, are not detected unless blood
testing is performed. Anesthetic agents are processed through the body by the liver and kidneys.
Any disorder regarding these organs can increase your pets anesthetic risk. For this reason, we
highly recommend pre anesthetic blood testing to place your animal in the lowest possible
anesthetic risk category. Results are immediately available, and you will be notified in the event of
abnormal results. ***Blood work is required on pets over 5 years old***
o ______ YES I want my pet to have a pre anesthetic blood test.
o ______ NO, I do not want a pre anesthetic blood test.
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Home Again Microchip: Has your dog or cat ever been lost? Scared by thunderstorms or
fireworks and escaped your yard? Animal control receives thousands of animals each year, that
they must adopt to new homes, or euthanize, when families are out searching for those pets. To
help insure that you receive your beloved pet back as soon as possible, we recommend and offer
Home Again Microchips. Iso microchips can be read in the United States and in Europe. Price
$55.00
o ______ YES I want my pet to have a Home Again Microchip placed.
o ______ NO, I do not want a Home Again Microchip placed in my pet.
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Print Name
________________________________________________
___________________________
Signature
Date