I am the owner or agent of and have the authority to execute consent for the surgical/medical procedure known as
The reasons why this operation/procedure is necessary, its advantages, possible complications, and possible alternative modes of treatment have been discussed with me. With full understanding of the above, the undersigned owner/agent authorizes
to perform, under any anesthetic deemed advisable, said operation/procedure. I understand that further procedures may be therapeutically necessary based on findings during the operation/procedure, I consent to those procedures, their additional cost, and any unexpected lifesaving emergency care deemed necessary by the attending veterinarian.
I understand that risks and potential complications exist with anesthesia and surgery. These include, but are not limited to:
• abnormal reaction to anesthetic agents, self-inflicted injury during anesthesia recovery (i.e., fractured legs, head trauma), muscle and nerve damage, dehiscence of incision, colic, post- operative infection, equipment failure, and death.
• Surgically removed tissues may be processed at additional costs to establish an accurate diagnosis.
If applicable, the insurance company has been notified and permission to proceed was received on
I acknowledge and understand that the procedure, its consequences, and subsequent risks have been explained to me, and I have addressed any questions or concerns I may have. I also realize that results cannot be guaranteed.
The estimate charges for the above mentioned procedure is
charges may vary depending on the findings and diagnostics. Full payment is due at the time of discharge.
I have read this agreement, “Consent for Surgery and Anesthesia,” and fully understand its terms. I intend my signature to be an authorization for surgery and complete liability release to Paddock Equine Veterinary Services, PA.
