Surgical Consent Form

Name*

First Last

Are you the person responsible for decisions and accounts?*

Yes
No

This person should be the owner on account, responsible for decisions and payments and of legal age.

Email*

Phone number you can be reached at during the surgery?*

Please keep your phone on and be available to answer it while we have your pet in the clinic.

Pet Name*

Date and Time of your appointment*

What surgery is your pet booked for?*

Is there any change in your pets medical condition since we last saw them?*

Is your pet on any Medications/Supplements/CBD oil. If yes, What is the names, dose, strength of each and WHEN WAS THE LAST DOSE GIVEN?*

Is your pet aggressive where we need to take extra precaution?*

Do you have pet insurance? If so what's the policy number and company name?*

I understand not to feed my pet after midnight, the night before surgery. And I agree IF I do feed my pet, there will be a $250 charge for this cancelled appointment.*

Yes

Your pet CANNOT have food within 8 hours of surgery time. PLEASE take the food away from your pet before midnight to ensure your pet does not eat in the morning. (NO BREAKFAST or TREATS IN THE MORNING). If your pet eats, your surgery appointment will need to be re-scheduled and there will be a $250 charge for the cancellation of your pets surgery on this day. Your appointment will be booked for the next available surgical time.

I understand I can give water up to the time of the appointment.*

Yes

I understand the procedure protocols*

Yes
No

The nature of such services has been described to my satisfaction, and while I accept all procedures to be done to the best abilities of the professional staff, I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure. I hereby release Roncesvalles Animal Hospital and staff from any, and all, liability arising from the surgical procedure(s), to be performed on my pet. In particular, I understand that in the event that the treatment requires the use of anesthesia, that there is a risk every time an anesthetic is used.

I authorize the attending doctor to care for my pet*

Yes
No

The performance of the identified procedures and the use of associated anesthetics and other medications. I also understand that unforeseen conditions may be revealed during the identified procedures which, in the opinion of the attending veterinarian, require more extensive or different procedures or treatments. I understand that reasonable efforts will be made to contact me to explain these procedures and treatments and obtain my instructions regarding them. However, if the efforts are unsuccessful I authorize the performance of any procedures and treatments which are necessary in the professional opinion of the attending veterinarian. Additional charges may apply. We will make every effort to keep within the estimate but sometimes procedures take longer than expected or differ from the estimate and the price may vary.

I agree to the clinic fees, with a 50% deposit and the balance paid the time of pickup.*

Yes

To pay the total as per the estimate given, for the above procedures and related clinic fees. I will pay a deposit prior to the procedure and the balance at the time the pet is discharged and hereby acknowledge my indebtedness for this amount. In the event that the pet referred to above is not claimed by the person giving consent within ten (10) days of completion of treatment and convalescence or of any ancillary services provided by the Roncesvalles Animal Hospital, the pet shall be deemed to have been abandoned, and the Clinic shall be entitled to transfer the pet to an animal shelter or to a third (3rd) party owner. The Clinic waives its lien rights under the Repair and Storage Liens Act. Abandonment does not release me of my obligation for payment of services rendered.

I agree to a $250 deposit for laparoscopic procedures*

Yes
This surgery is N/A to my pet

We require no less than 2 weeks notice to cancel or reschedule the laparoscopic procedure. Upon booking, a $250CAD deposit is required and is mandatory. This deposit will be used towards the final payment OR be subject to no refund upon cancellation of the booking, if 2 weeks notice is not given.

At times during your pet’s visit, we may take pictures. Your consent here will act as authorization to use these pictures on Roncesvalles Animal Hospital Facebook, Instagram and social media pages.*

Yes
No

Cancellation Policy*

I agree to the cancellation policy

For payments we are accepting all major credit cards, Debit, e-transfers or cash.
Any verbal or physical abuse will not be tolerated and services may be withdrawn for anyone not conducting themselves in an appropriate manner.
Missed drop off or cancellation within 72 hours of SURGERY time - $250

We appreciate your consideration and understanding of this policy.

I agree*

I have read and understand this complete form, any questions and concerns will be noted in the below field.

Any other information we should know?

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