Client Consent Form

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Client ConsentForm

Date

Name(Required)

First Last

Email(Required)

Patient Name(Required)

Patient Name

Referring Hospital

Attending Veterinarian (who referred you for surgery with Dr. Luther?)(Required)

First Last

Surgery to be performed(Required)

Anatomic site

Untitled(Required)

I consent to this surgical procedure for the above patient.

I have discussed the aforementioned surgery and the importance of pre-surgical blood testing with the attending veterinarian. I understand that there are risks and hazards involved with the recommended surgical procedure, including anesthetic risk. The attending veterinarian and referring hospital will be responsible for monitoring and recovering my pet during this anesthetic procedure. I realize no guarantee or warranty can ethically or professionally be made regarding the results or cure.

Surgical Risks May Include

Infection, which may require additional testing and medication at an additional cost
Hemorrhage or bruising
Swelling or edema postoperatively
It is rare, but anesthetic complications up to and including death can occur

Strict adherence to the post-surgical care and medicating of your pet will minimize these potential complications and serious problems are very uncommon in most cases. Your pet will need to be under exercise restrictions until healing is confirmed by medical progress examinations. Please do not return to full activity, bathe, allow to run, play or swim until released by Dr. Luther or your primary care veterinarian. Using the ecollar to prevent self-grooming is critical to avoid incisional infections.

Heartland Veterinary Surgery occasionally feature patients on its Facebook, Instagram, YouTube or other social media sites and in publications (print or online). With your permission, we may share your pet’s picture, video or story. We may mention your pet by name, but never the owner’s name. The surgeons and staff would be grateful that you’ll be helping other pets by educating pet owners, veterinary technicians and veterinarians.

Do we have your permission to share your pet’s picture, video or story?(Required)

Yes

Pet Owner/Agent Signature(Required)

Date(Required)

Phone I Can Be Reached at Today(Required)

Witness signature for phone consent

Date

Witness Name(Required)

First Last