Consent Form

Thank you for giving us the opportunity to care for your pet! To ensure the best care possible, please take the time to fill in this form completely.

Get Started

Consent Form

Client's Name *

First

Last

Patient's Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Species *

Sex *

Male
Female
Spayed Female
Neutered Male

Phone *

Color *

Referral Hospital

Birth Date

Contact number where you can be reached today *

I, as the owner or party responsible for the above pet hereby authorize the doctors and staff of Northwest Veterinary Surgical Services to perform the following procedure(s): *

On the

Left
Right
Both
Non-applicable

Choose one

I understand that anesthesia may need to be administered as part of any diagnostics and/or surgical procedures. It has been explained to me that conditions may arise during this procedure whereby a different or additional procedure may need to be performed. I understand that all efforts will be made to contact me prior to such procedures being performed, but there may be instances where it is in the best interest of my pet to proceed without delay.I have been advised as to the nature of the procedure(s) and inherent risks involved. I understand that complications, including but not limited to, infection, cardiac arrest, and death could result. I acknowledge that no guarantee has been made as to result or cure. Northwest Veterinary Surgical Services occasionally feature patients on their Facebook, Instagram, YouTube or other social media sites and in publication (print or online). With your permission, we may share your pet’s picture, video or story.We may mention your pet’s name but never your last name. Dr. Belknap and staff would be grateful that you’ll be helping other pets educating pet owners, veterinarians and veterinary technicians.

Signature *

Clear Signature

Signature of legal owner or authorized representative

Signature *

Clear Signature

Signature of witness at hospital

Consent Form

Ready to make an appointment?

Phone

Address

Hours

Have a question?