Procedure Consent Form

Full Name *

Preferred pronoun

Email Address *

Phone Number *

Address*

City *

Province*

Postal Code *

Pet's Name *

Pet Species *

Cat
Dog

Reproductive Status *

Your pet's age *

Your pet's breed *

Procedure date *

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY, AND INDICATE YOUR CONSENT AT THE BOTTOM OF THIS SECTION.

I understand that there can be no guarantee as to the animal’s condition or the outcome of any procedure and/or treatment.
I understand that there is always risk inherent to anesthesia. The following precautionary measures have been recommended: fasting, intravenous fluids and pre-surgical blood work; and I have accepted or declined them as stated on the treatment plan.
I also understand that unforeseen conditions may be revealed during the above procedures, which in the opinion of the Veterinarian require more extensive or different procedures or treatment. I understand that reasonable efforts will be made to contact me to explain these procedures and/or treatments and obtain my instructions regarding them. However, if the efforts are unsuccessful, I consent to such further operation(s) and/or procedure(s). I understand that I am responsible for all charges incurred.
I consent to the assistance of other hospital personnel at the Veterinarian’s direction considered necessary or advisable by the Veterinarian in whose care I hereby place.
I understand that Wellesley Animal Hospital is not staffed overnight.
I understand that if my pet(s) should be found to have fleas or other external infectious parasites that s/he will be treated at my cost.
I understand that if I should leave my animal(s) for more than 3 days, or their belongings for more that 30 days, that they shall be considered abandoned and will become the property of Wellesley Animal Hospital.

I certify that I have read, have interpreted and fully understand the above, and give my consent for the procedure(s) detailed in the attached treatment plan *

Yes

Please attach the treatment plan for which you are giving your consent here *

Would you prefer a regular e-collar, a soft cone, or a surgical onesie for your pet to wear home? *

Regular E-Collar ( approx $7-$20 depending on size)
Soft Collar (approx $25 -$50 depending on size)
Surgical Onesie (approx $24-$38 depending on size) *cannot be used for feline neuters and we may require a cone in addition to this option
N/A, dental or other procedure not needing cone/onesie

If your pet is not microchipped, would you like one administered while they're here today? ($135.00 plus tax) *

Yes
No

Would you like us to perform therapy laser post surgery? This promotes healing and reduces inflammation ($31.00 plus tax) *

Yes
No

Would you like to go home with probiotics (Forti Flora SA)? This reduce chances of soft stool from anesthesia/ medication (10 days worth, $16.73 plus tax) *

Yes
No

What is the best method to contact you on the day of the procedure? Is there any time(s) this day in which you are not available? *

Did you administer any pre-visit medication? If yes, please indicate what medication was given and when *

The following questions apply to dental procedures only, please select N/A if not applicable.

I prefer to be called before any extractions/treatments are performed *

Yes, please call me before extractions/treatments
No, please proceed as required regardless of cost
N/A

If I cannot be reached, I authorize you to proceed with all necessary dental procedures regardless of cost *

Yes, please proceed as required regardless of cost
No, please do not proceed without my authorization. By clicking this option, I understand that if I cannot be reached and do not return the call within 10 minutes, my pet may be woken up from anesthesia, requiring a separate anesthetic event (at additional cost) to perform needed treatments. If anesthetic safety is a concern, the veterinarian may choose not to wait the 10 minutes before waking my pet up.
N/A

Digital Signature *

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *

Procedure Consent Form

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