Surgery Consent Form 

Name *
Would you prefer a call or text when surgery is completed and your pet is waking up? *
Is your pet experiencing any of the following symptoms? Check all that apply or None *
My Dog is current on Monthly Heartworm Prevention *
If you answered "no" to the above question we recommend having a heartworm test performed as a heartworm positive dog has an increased risk under anesthesia. I authorize Pittsboro Animal Hospital to perform a heartworm test at an increased cost *
I the undersigned, certify that I am the owner, or authorized agent for the owner, of the animal described above. I authorize the doctor on duty and assistants to perform the procedure(s) listed above and on the attached estimate, including administration of pain relief medications, sedatives and/or anesthetics, as well as any necessary and appropriate medical, radiological, surgical, nursing,diagnostic, and/or emergency care for the animal. I have been advised as to the nature of the procedures and the potential risks. I also understand that no guarantee of successful treatment can be made. I also understand that the estimate is just an estimate and other costs may arise related to the care of my pet and take responsibility for such charges. I have read and understand the reasons for and the risks of the above and attached authorized procedure(s), and assume full financial responsibility for all charges and services incurred to the described animal. By typing my name in the box I an signing this Surgical Consent Form.: *
Date *