Arroyo Animal Clinic

Surgery Consent Form

Make your next visit more efficient by filling out our form from the comfort of your home!

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Vet Near Sunnyvale, CA

We look forward to your visit.

Please fill out this form as completely and accurately as possible before your visit.

Pet Information

Pet's Name *

Contact Information

Owner's Name *

First

Last

Email *

Phone *

Additional Phone

Secondary Contact: *

First

Last

* This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

Secondary Contact Phone *

Today's procedure is: (example: lump removal, exam, etc.) *

Additional Services Desired While Patient Is Sedated

Please select any/all that you would like us to provide while your pet is sedated

Implant Microchip
Nail Trim
Express Anal Glands
Other (specify below)
I would like an e-collar for my pet

Please specify the additional service(s) you'd like provided to your pet *

I have restricted food from my pet since 10 pm last night. *

I have not given my pet any medication during the previous 24 hr's, unless directed to do so. *

If given, please note medication name(s), dose and time *

My pet does NOT have any symptoms which may indicate illness other than the ones known. These symptoms include coughing, sneezing, vomiting, diarrhea, inappetance, weight loss, excess thirst or elimination, rashes. *

Yes, they do.
No, they do not.

If your pet has been debarked, or had anesthetic problems before-please describe below *

Authorization

I authorize anesthesia/sedation for my pet. The nature and risks of this procedure have been explained to me. I understand some risks always exist with anesthesia and/or sedation, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any questions have been answered to my satisfaction. *

I have read, understand, and authorize

I authorize Arroyo Animal Clinic to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical complications or otherwise unforseen circumstances. I understand there are rare complications associated with any anesthetic procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks and understand the veterinarians and hospital staff will try to minimize such risks. I will not hold Arroyo Animal Clinic, the veterinarians, or any staff member liable for any complications that may arise. *

I have read, understand, and authorize

If a problem arises or is noticed, besides what is known prior to today's procedure, and needs attention, which goes beyond the original estimate, we will make efforts to contact you by phone to go over the options. If we cannot contact you, please choose ONE of the options below. *

Use best judgment and do whatever is necessary. I accept all additional charges.
Use best judgment, but only spend up to (fill in below)
Do not perform any additional procedures.

I am willing to spend an additional (please fill in below) *

Payment due upon services rendered. *

I have read, understand, and agree.

I HAVE READ AND FULLY UNDERSTAND THIS ANESTHESIA CONSENT FORM *

Signature of Responsible Party *

Date *

Website

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Request a Veterinary Appointment in Sunnyvale, CA

We proudly serve the pets of Sunnyvale, CA, and surrounding areas. You can count on our pet hospital to present you with many options to suit your pet’s health needs. Easily request an appointment for your pet using our online system on PetDesk and keep up with your pet’s health by downloading our app!

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