Owner's Name:________________________________________________________

Address:_____________________________________________________________

Patient's Name:________________________________________________________

Species:______________________________________________________________

Breed:_______________________________________________________________

Sex:_________________________________________________________________

Date of Birth:__________________________________________________________

I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent.

I hereby give Dr. _____, the ________(name of veterinary facility), and any authorized agents, staff, or representatives consent and authority to perform the following procedures or operations: ___________________________________________________________________

The nature of these operations or procedures has been explained to me, and I understand what will be done.

I have also been informed that there are certain risks and complications associated with any operation or procedure of this type. They have been explained to me as well. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures.

I authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedure. I have been informed that there are risks associated with the use of any medication.

I understand that hospital support personnel will be used as deemed necessary by the veterinarian.

Signed:__________________________________

Date: ____________________________________

I certify that if I am signing as an agent, I have the authority to execute this consent

Name:_____________________________________
              (Please Print)

Signed: ____________________________________
              Signature of Authorized Agent

Date: ______________________________________

Notes for Potential Users of the Standard Consent Form
(Not to be printed as part of form)

1. It should be understood that this form will not protect the veterinarian from liability for malpractice (negligence). Releases from liability for malpractice, executed by a client prior to the occurrence of the negligent act, are generally disfavored by the courts. The proposed form is designed merely to protect the veterinarian from liability for intentional acts such as interference with another's property, which means, in fact, permission to do the operation(s) or procedure(s).
   
   
2. Legal opinion should always be secured before implementing any forms as part of clinic policy or procedure.
   
   
3. When more than one veterinarian is involved in the practice, the name of the hospital or clinic should be shown as well as the name of the individual veterinarian. If the number of veterinarians in a clinic or hospital is few enough to make it practical, all consents should include not only the hospital or clinic name and the name of the individual veterinarian, but also the names of other veterinarians practicing in the clinic as partners or otherwise. Where appropriate, such information should be preprinted.
   
   
4. The description of the procedures should be brief but sufficiently comprehensive to cover the situation.