Hospitalization / Surgery Permission to treat in El Paso, TX

To the Client: You have the right, as client, to be informed about your pet’s condition and the recommended surgical, medical or diagnostic procedure(s) to be used, and the risk and hazards involved with such procedures. This disclosure is not meant to scare or alarm you, it is simply an effort to make you better informed so you can give or withhold your consent:

Owner's Name:*

First Last

Phone*

Pet's Name:*

I, the undersigned owner of the pet identified above, certify that*

I am 18 years of age or older
I am NOT 18 years of age or older

I/we voluntary request that the Montana Animal Clinic, assistants, and staff treat my pet’s condition which has been explained to me and just as there are risks and hazards in continuing the present condition without treatment, there are also risks and hazards related to the performance of the surgical, medical, and/or diagnostic procedures planned for my pet. I/we realize that common to such procedures is the potential for infection, blood clots in vessels and lungs, hemorrhage, allergic reactions, and even death. I/we also realize that the following risks and hazards may occur in connection with this particular procedure.*

I/we voluntarily consent and authorize procedure(s).
I/we DO NOT voluntarily consent and authorize procedure(s).

I/we hereby give Montana Animal Clinic permission to take photographs of me and my pet for the purpose of posting on Montana Animal Clinic Facebook, Yelp and Google. I hereby release and discharge Montana Animal Clinic from any and all claims arising out of use of the photos:*

Yes
No

I/we understand that my pet’s doctor may discover other different conditions, which require additional or different procedures than those planned. I/we authorize my pet’s doctor to perform such procedures, which are advisable in his/her professional judgment.*

Yes
No

I understand the following ( Select once you have read each statement)*

I understand that anesthesia involves additional risks and hazards but I/we request the use of anesthesia for relief and protection from pain during the procedures.
I/we have been given the opportunity to ask questions about my pet’s condition, alternative forms of anesthesia and treatments, risks of non-treatment, the procedure to be used, and the risk and hazards involved. I/we believe that I/we have sufficient information to give this informed consent.
I/we understand that the Montana Animal Clinic is officially closed after 6 PM and that all doctors and staff exit the premises. If I/we authorize overnight hospitalization for my pet, I/we understand that the pet is technically unsupervised from 6 PM until 7 AM. I/we are aware of the option to transfer my pet to the El Paso Animal Emergency Center for overnight care at my own expense.
I understand that a rabies vaccine will be given if needed to comply with city ordinance. Any animal found to have fleas or ticks will be treated at the owner’s expense.

I state that my pet has not had any food for the last ________ hours.*

Agreement*

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 agree to pay a deposit of __100__% of the estimated fees, assume financial responsibility for the remaining fees, and provide payment via cash, credit card, or check at the time my pet is discharged from the hospital.

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me: (check one)*

The staff DOES have my permission to provide such treatment and I agree to pay for such services.
The staff DOES NOT have permission, as I/we are opting for (DNR) Do-Not-Resuscitate Order.

Agreement

I have read and fully understand the terms and conditions set forth above.

Electronic Signature: By entering my FULL NAME*

Date