Surgery Form 3 Anesthesia Consent - Rogue Equine & Companion Animal Clinic

Owners First and Last Names*

First Last

Emergency Phone Number - Mobile*

Please provide a phone number(s) where you may be reached at ALL times while your pet is in our care.

Your animal's name?*

Your animal's age?*

Sex*

Male
Male Neutered
Female
Female Spayed

Your animal's species?*

Your animal's breed?*

Your animal's approximate weight?*

Procedure to be performed:*

Please state the procedure recommended to you by the veterinarian. Noting this incorrectly may cause delays. If you are unclear, please call (541)826-9001 and ask to speak to the veterinarian recommending the procedure.

Authorization and Risk Assessment:*

I authorize anesthesia and surgery for my animal. The nature and risks of this procedure(s) have been explained to me. I understand that some risks exist with anesthesia and/or surgery. My signature on this consent form indicates that any questions have been answered to my satisfaction.
I authorize Rogue Equine and Companion Animal Clinic to perform additional diagnostic, treatment, or procedure(s) deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. While Rogue Equine and Companion Animal Clinic provides the highest quality of anesthetic monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical 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 that the veterinarian and hospital staff will try to minimize such risks. I will not hold Rogue Equine and Companion Animal Clinic, veterinarians, or any staff member liable for any complications that may arise.
I HAVE READ AND FULLY UNDERSTAND THIS SURGERY AND ANESTHESIA CONSENT FORM.

I AGREE AND CONSENT

Date of agreement and consent*

Signature*

Sign with finger if mobile phone or tablet, drag mouse if PC or Mac.

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Email

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