Surgery Consent Form

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Thank you for entrusting us with your pet’s care! Please take a moment to complete this form for your pet’s upcoming surgical procedure and don’t hesitate to contact us at 615-383-1000 or at [email protected] if you have any questions.

First & Last Name

Someone authorized to make decisions for your pet in the event of the primary contact cannot be reached

Include name, strength, dose and frequency of medication, please be prepared to share the date and time the last dose of each medication was given when your pet is admitted.

Please understand that certain additional procedures will have to be approved by the attending veterinarian.
While your pet is under anesthesia, we can implant a microchip. Microchips have helped reunite thousands of lost pets. With a current annual membership (first year included with implant) the microchip also includes 24-hour emergency support, free poison control, and more. Would you like us to microchip your pet today?*

The attending veterinarian may recommend an e-collar to prevent your pet from aggravating the surgical site. Would you like an e-collar?*

Limiting activity after surgery is necessary for a smooth recovery. Would you like a post operative oral sedative for your pet?*

It is important that patients undergoing anesthesia be fasted before the procedure, while water is ok – all food should be withheld from your pet after 8:00pm the night before the procedure.

By typing my name below, I hereby state that I am the owner or authorized agent for the owner of the animal identified above and authorize the veterinarians at Belmont Animal Hospital to perform such diagnostics, treatments, and/or surgical procedures as deemed necessary for my pet. The nature and risk of the procedure(s) have been explained to me and no guarantee has been made as to the results or cure. I fully understand that there may be risk and the potential for complications including death. I agree to pay, in full, for services rendered including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances and understand that an itemized estimate for the cost of the procedure(s) is available upon request. I have read the above conditions for treatment and acknowledge that I may have a copy of this form, if requested.

MM slash DD slash YYYY

This field is for validation purposes and should be left unchanged.

What's Next

  • 1

    Call Us or Schedule an Appointment Online

  • 2

    Meet with a Doctor for an Initial Exam

  • 3

    Put a Plan Together for Your Pet