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Surgery Authorization Form

I hereby entrust Smithfield Animal Hospital to care for my pet during their stay. I am the owner, or a representative of the owner, of the animal presented and have the authority to execute this consent. I have been advised as to the nature of the procedure to be performed and the risks involved. I understand that with any anesthetic procedure, there are associated risks up to and including death but the doctors and staff will take all reasonable precautions including bloodwork and careful anesthetic monitoring to minimize risk of complications. Understanding that, I hereby consent and authorize this hospital to perform the requested anesthesia and surgical procedures. I understand that I must provide phone numbers where the hospital can reach me or a contact person whom I have authorized to make medical decisions.

We anticipate an uncomplicated procedure today, but we are prepared for complications if they arise. Sometimes during a procedure, we recognize other concerns that need to be addressed or learn the true scope of the problem we are treating. We realize that you may not have planned for these additional services. We must be able to reach you by phone if we find any issues in order to recommend a treatment plan and seek authorization to proceed (cost estimates will be provided). We will make every reasonable attempt to reach you prior to proceeding with any additional services. However, procedures requiring anesthesia are time-sensitive and provide a narrow window of time in which to reach you. For your pet’s safety, please list where you or your agent can be reached without delay.

In the event you or your authorized contact person are not reachable, would you prefer us to proceed with the additional recommended treatment? Please initial your preference:
Please proceed with additional treatment. I understand that there will be additional charges for further treatments.
Please do not proceed with any treatment beyond the initial treatment plan, unless my pet's safety requires it.

Standard pickup time is between 3 and 5 pm, but due to the nature of hospital operations and anesthesia recovery, actual discharge time may vary. We will contact you after the completion of your pet’s procedure to let you know the earliest that they will be available for pickup. In the event that you are unable to pick up your pet on the day of surgery, or it is medically necessary, they may be hospitalized at the facility for further observation (additional fee).

I understand that the safety of my pet is the overriding priority. I understand that any price quote I have been given is an estimate and if complications are involved, or the procedure is of greater dimensions than anticipated, the price may be higher.

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Anesthesia Questionnaire

 Please complete the morning of your pet’s procedure
Has your pet eaten in the last 8 hours?
Are there any additional services you would like us to perform while your pet is in the hospital (charges may apply)?
A permanent form of ID for travel or in case your pet is lost/stolen.
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