Newton Animal Hospital
7010 King George Blvd
Surrey, BC V3W 4Z9
Anesthesia or Sedation/Surgery Consent Form
Client's Name:
Address:
Pet's Name:
Species:
Breed:
Sex:
M( ) F( )
Color:
D.O.B
Telephone
The purpose of this form is to clarify communication between Newton Animal Hospital and our clients in order to maximize the
quality of care your pet receives while staying here for surgical procedures. We believe informed owners make happy clients!
Please read the following carefully.
I,_____________________, am legally responsible for the care of the following animal, and am authorized to make decisions
regarding surgery and medical treatment while hospitalized at Newton Animal Hospital.
Phone Number Where I May Be Reached If Necessary: ______________________________________
In the event of an unseen emergency where upon I cannot be reached, I authorize the following person to act in my behalf
regarding decisions relating to the care of my pet. If this person cannot then be reached, the veterinarian is authorized to act in
the best interest of my pet.
Name of Alternate Contact: ____________________________________Phone Number:____________________
Consent for Surgery
By signing below, you acknowledge that you understand the nature of the procedure to be performed upon your pet and give full
permission for it to be performed according to accepted standards of practice. In the event of emergencies or unforeseen
complications, reasonable attempts will be made to contact you (or your alternate) for your preferences amongst viable medical
or surgical alternatives.
Procedure(s) to be performed; please check at least one.
 Spay or Neuter
 Wound Repair
 Cosmetic
 C-Section
 Orthopedic: Left / Right / Both (please circle)
 Lump Removal
 Dewclaw Removal: Front / Back / Left / Right (please circle)  Exploratory

 Eye Surgery: Left / Right / Both (please circle)
 Tattoo
 Microchip
 Demat
 Other: ___________________
Pre-anaesthetic Evaluation in the form of physical examination is carried out prior to all surgeries, however it can only provide limited
information to the veterinarian. For this reason, we recommend that all patients older than seven years have some form of pre-anesthetic testing.
Anaesthetic and analgesic protocols remain at the discretion of the attending veterinarian. We will make every attempt to make this procedure
as stress-free and painless as is reasonably possible for your pet. If you have any concerns in this regard, they should be addressed to the staff
before completing this form.
Discharge of patients shall be at the direction of the attending veterinarian. Discharge of patients prior to the time approved by the veterinarian
may be risky to your pet’s health and shall only be permitted following the completion of an “Premature Discharge Statement” in order to
establish appropriate responsibility for your pet in such a circumstance.
Estimates of charges for all procedures will be happily provided by your veterinarian. We will adhere to our estimates in all but emergency or
unforeseen circumstances. Your signature below indicates your awareness of the estimated costs for service and your agreement to cover these
costs at the time of service on the usual terms (cash, VISA, MasterCard, Interac).
I, the undersigned, accept these terms for the treatment of my pet and understand fully the nature and the inherent risks of the above procedure(s).
These have been explained to my satisfaction, and I feel comfortable with the compassion and care that the veterinarians and staff of Newton
Animal Hospital will provide for my pet.
Signature:__________________________________________
Date: _______________________