Surgery Authorization Form"*" indicates required fieldsName* First Last Date* MM slash DD slash YYYY Phone*Client #Patient*BreedSexAgeCan we text if unable to reach by phone: Yes NoI, certify that I am the owner or responsible party of the patient described above, being assessed/treated today. I have the authority to execute this consent. I am over the age of 18. I hereby authorize the DVM of MSVC, PC and the facility's authorized staff or agents consent to perform said procedures*Client Initial herePLEASE NOTE BUDGET HEREProcedures: Cat Spay Cat Neuter Dog Spay Dog Neuter Pregnant Fee In Heat Combo Test Pre-Anes Dental Exploratory Cystotomy Laceration HW Test CBC Extractions Mass Remove Microchip C-Section Fecal Sick Profile Rabbit Cat Declaw K9 Dewclaw OFA Xrays Histo Culture Blood Work Exam Vaccines XraysAdditionalI understand that during the performance of the examination, etc today that risks and potential complications involved have been explained to me. I understand what will be done and understand that additional procedures may be necessary and will be at additional fee.I understand & acknowledge that MSVC is unstaffed between hours of 6pm and 7am M-F and most hours on weekends & holidays. I understand that my pet will be left unattended during those times & during any overnight and/or boarding with MSVC. I acknowledge that I have received MSVC’s notice on its lack of fire suppression & overnight staffing. I understand & acknowledge that MSVC is not equipped with an on-site fire suppression sprinkler system.*Client Initial:I hereby acknowledge I have been given the option for a verbal estimate (no guarantees of final cost) of charges and accept financial responsibility for the care of this animal. I also understand that ALL charges will be PAID IN FULL at the time of release/pick up/discharge and that a deposit may be required. I also acknowledge that MSVC does NOT do billing of any kind. I understand that the DVM can charge as necessary for services & All prices are subject to change. By signing, I am in agreement that all services are PAID In Full at time of service.Signature*Date* MM slash DD slash YYYY Staff Initials*PhoneThis field is for validation purposes and should be left unchanged.
