Surgical Consent Form - Flatbush | Heart of Brooklyn Veterinary Hospital in Brooklyn

Contact Information

Client First Name *

Client Last Name *

Pet Name *

Primary Phone *

Secondary Phone

Email *

After Procedure

Would you like us to text you after the procedure, or would you prefer a call? *

Text

Call

Anesthetic and surgical procedure(s) to be performed: *

I, the undersigned owner or agent of the pet identified above, authorize the staff of Heart of Brooklyn Veterinary Hospital to preform the above procedure(s). *

I have read and agree.

Other medications(s), please specify and note last time given

When was the last time fed? *

Anesthesia Consent

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have. about those risks with the attending veterinarian before the procedure(s) is/are initiated. *

I have read and understand the above.

I authorize Heart of Brooklyn Veterinary Hospital to administer sedatives and use general anesthesia on my pet for the services or procedure outlined in the associated treatment plan. I have discussed the plan anesthesia with a veterinary professional to my satisfaction and amaware I may contact Heart of Brooklyn Veterinary Hospital with my questions. I understand that anesthesia poses a risk to my pet, regardless of health status. In the event of unforeseen complications, I give permission or the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. *

I authorize the above.

In the Event of Cardiac Arrest During Hospitalization (heart or breathing stops) I request emergency and life-saving procedures (including cardiopulmonary resuscitation) be preformed immediately on my pet. I understand I will not be contacted prior to these actions and give permission for the doctors and staff at Heart of Brooklyn Veterinary to take reasonable measures in treating my pet. I accept all additional charges that are incurred as a result of such action. I understand initiating CPR does not guarantee survival. *

I authorize the above.

Financial Options

I authorize Heart of Brooklyn Veterinary Hospital to perform the procedure(s) outlined in the associated treatment plan on my pet. I understand the itemized treatment plan is a good-faith representation of what will be preformed during this procedure. If Heart of Brooklyn Vet encounters any NON-EMERGENCY, unexpected complications, or medical conditions that require the treatment plan to be altered, every effort will be made to contact me as these issues arise. In the case the hospital staff is unable to contact me, Heart of Brooklyn Vet will follow my instructions as outlined below. *

I authorize the above.

If unexpected complications or medical problems arise during my pet's hospitalization and I cannot be reached at my contact phone number: Perform additional treatments/services deemed medically necessary by the attending doctor as detailed below. I understand these services were not listed on the treatment plan presented to me, and thus additional charges are my responsibility (due at discharge). Heart of Brooklyn staff will make every attempt to contact me at the numbers I provided before proceeding with the additional services. Treatments/diagnostics that are purely elective, or that will not benefit my pet's immediate health will not be preformed without permission.

Select a limit you authorize: *

Media Release: Do you grant Heart of Brooklyn Veterinary Hospital permission to use your pet's images on our social media platforms? *

Yes

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is preformed, as such as follow up radiographs, re-check physical exams and the additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree

Date *

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Surgical Consent Form - Flatbush

Contact Information

After Procedure

Anesthesia Consent

Financial Options

New Patients Welcome