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Surgical Consent Form

Please complete the form below and a member of our team will get back to you as quickly as possible to confirm your appointment. If this is an emergency situation, please call us at 860-669-5721.

Owner's Name *

First

Last

Email *

Phone *

Please provide a number where you can be reached if we have questions or concerns while your pet is hospitalized for their procedure.

Pet's Name *

Procedure: *

List of pet's current medications with date/time of last dose given:

I hereby warrant that I am the owner or the authorized agent for the owner of the above pet and does hereby request, consent and authorize Clinton Veterinary Hospital, its owners, veterinarians, personnel and agents to perform the procedures listed above. *

I have read and agree to the above terms

I understand the nature of the procedure(s) or operation(s) to be performed and that unforeseen conditions may be rerevealed or develop that in their exercise of professional judgement, will necessitate the extension of the original procedure(s) or different procedure(s) or operation(s) than those set forth above. Therefore, I hereby authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgement. *

I have read and agree to the above terms

I am generally aware of the risks and consequences associated with the procedure(s) or operation(s) and acknowledge that no guarantees have been made as to the results of operation(s) or procedure(s) and regardless of the results, I will remain fully responsible for the costs of all services provided by The Clinton Veterinary Hospital and its authorized agents and professionals. *

I have read and agree to the above terms

I agree to pay for the cost of all services rendered upon discharge from the hospital. I also acknowledge the payment policy and that no payment plans are offered and that payment in full is due at the time of service. *

I have read and agree to the above terms

I understand that if my pet is over 6 months of age, Pre-Anesthetic Bloodwork ($140) will be performed before surgery. A 4DX ($92) (Lyme, Anaplasma, Ehrlichia and heartworm test) is also required and will be performed if one has not been performed within the past 12 months. *

I have read and agree to the above terms

My Pet is under 6 months of age, and I authorize Pre anesthetic blood testing for my pet *

By declining this testing, you recognize that your pet is at increased risk of anesthetic complications possibly including death. *

I have read and understand

I authorize Home Again Microchip placement ($75) and understand that this includes the first year of registration. *

Visit Clinton Veterinary Hospital

The Clinton Veterinary Hospital in Clinton, CT proudly serves the pets of Madison, Guilford, Clinton, Westbrook, Deep River, Old Saybrook, Chester, Ivoryton, Essex, and Killingworth. We look forward to seeing you and your pet. You may request an appointment by clicking the button below.

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