Surgical Authorization Form

Save time at your pet’s surgery appointment. Complete your surgical authorization form online from any device at any time before your visit.

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Healdsburg Veterinary Hospital Surgical Authorization Form

Please fill out this form as completely and accurately as possible so we can best prepare for your pet’s surgery.

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SURGICAL AUTHORIZATION:

Name

First

Last

Pet's Name

Date of Surgery

Surgery to be Performed

Before putting your pet under anesthesia, we routinely perform a full physical examination and blood work on all pets’ undergoing anesthesia to maximize patient safety. Pre-surgical blood work and physical examination allows us to best minimize anesthetic and surgical risks for your pet. Please choose ONE:

Yes, I authorize(d) pre-anesthetic blood work for my pet (additional charges may apply)
No, I decline all pre-anesthetic blood work recommendations for my pet given by the attending veterinarian and understand all associated risks

Depending on the surgery, your pet may have to spend the night or several nights at our hospital. We are not an emergency hospital and therefore do not have staff onsite 24/7. Our hours of operation are Monday - Friday: 8:30 a.m.-12:00 p.m.; 2:15 p.m. – 5:00 p.m. We are closed Saturdays and Sundays.

I acknowledge that continuous presence of personnel may NOT be provided at ALL hours – see our posted hours of operation above. Veterinary service during nighttime hours, some daytime hours, and/or weekends, is provided at the discretion of the veterinarian in charge.

I authorize the attending veterinarian to do the following while my pet is in surgery/under anesthesia. Please check only ONE:

Do whatever is in my pet’s best interest, our hospital does not need to contact you during the procedure.
Try to reach me at the number below, but if you are unable to reach me immediately, do what’s in my pet’s best interest.
Try to reach me at the number below, if I do not answer immediately then DO NOT do more extensive procedures. Please note that if you check this box we may not be able to do everything needed if we cannot reach you during the surgery. I understand that I may incur additional costs including anesthetizing my pet again at another time because of this decision.

If you need to cancel or reschedule your pet’s surgery appointment, we respectfully request at least 24 hours’ notice. Any cancellation or reschedule attempt made less than 24 hours from the scheduled surgery time or if you miss your pet’s surgery altogether, it will result in a cancellation fee of $148.80. Please type your initials.

Consent

I hereby consent and authorize Healdsburg Veterinary Hospital to receive, prescribe for, treat, or operate upon my animal.

Owner's Signature

Clear Signature

Today's Date

Phone Number (where owner can be reached in the next 3 hours):

Surgical Authorization Form

Healdsburg Veterinary Hospital Surgical Authorization Form

SURGICAL AUTHORIZATION:

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