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Surgery and Dental Consent and Agreement to Pay Form

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Surgery and Dental Consent and
Agreement to Pay Form

Please read, enter phone number, and sign

Patient's Name *

First

Last

By signing this form, you agree that you are the owner, or a representstive of the pet presenting to us and thus have the authority to execute all consent. You also agree that you understand all fees are to be paid in full at the completion of any visit or stay. You realize that actual expenses may differ from any estimates given prior, dependant on the patient's condition and length of stay in the hospital.

All pets are required to be current on vaccinations and tests at the time of procedure.

A $150 deposit towards the estimate is required for patients upon the scheduling of their appointment. If not taken at time of booking, please call in deposit payment to secure your pet's scheduled surgical appointment.

At the time of check-in, one or more emergency numbers will be requested from you. In the unlikely event unanticipated major medical attention is required for the well being of your pet, such treatment will be administered with every attempt being made to contact you. The welfare of your pet is our first priority. If we are unable to reach you, Orange Veterinary Hospital medical staff will make the best decision for your pet's health.

Please provide 2 emergency numbers that someone can be reached at anytime during your pet's stay.

Primary Phone Number *

Please enter a valid phone number incase we need to reach out while the patient is under anesthesia.

Alternate Phone Number

Please enter a valid phone number. Second owner or emergency contact.

You have received an estimate for services and accept and agree to the terms set forth in said estimate. Please initial below. *

Clear Signature

You authorize the direct veterinarians at this hospital to administer treatment as needed on the basis of findings during the course of the evaluation: to diagnose, prescribe, sedate, anesthetize, and/or preform surgery as their judgement may dictate to be advisable for the patients well-being.

If your pet is having a dental procedure, extractions may be necessary. Our staff performs dental x-rays prior to the procedure to help determine if oral surgery will be needed. Extractions are only done when medically necessary, and the doctor will determine what is best for your pet. (If you prefer a phone call prior to oral surgery being performed, please initial here *

In the event, we are unable to reach you immediately, the doctor will proceed as medically necessary.)

Owner's Name *

First

Last

Signature *

Clear Signature

Date *

Surgery and Dental Consent and Agreement to Pay Form

Surgery and Dental Consent and
Agreement to Pay Form

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