Hacienda Urbana®

Authorization for Anesthesia and Surgery

I, with signature below, as the owner and/or party designated responsible for the pet, certify that I am 18 years or older (initial) and authorize the veterinarians of Hacienda Urbana Veterinary Hospital to perform the procedures mentioned above. I understand that there are some risks associated with anesthesia and surgery, and affirm that I have discussed any and all of my questions and doubts about these risks with the veterinarian prior to starting any procedure. My signature below indicates that any questions I had regarding the following points were answered to my satisfaction:

  • Medical and surgical treatment options for my pet
  • Sufficient details about the procedure to understand what procedure would take place
  • Expectations as to what time frame my pet will recover and how recovery will take place
  • The most common and most serious complications that could occur
  • The duration and type of monitoring that the procedure will require

By accepting that all procedures will be conducted to the best abilities of the staff at Hacienda Urbana Veterinary Hospital, I understand that there is no guarantee of the results which can subsequently occur, after the animal is returned to the owner, if the owner does not follow prescribed, written instructions.

In case of an emergency of life or death, or any changes required during surgery, when the Hacienda Urbana staff is not able to contact to me, I give (initial) or do not give (initial) permission to provide any additional treatment or procedure and am responsible to pay additional costs for such services.

I have received an estimated cost of the procedures to be performed. This includes previous discussion of optional services that increase the safety of the procedure, including pre-anesthetic blood tests, fluid therapy, EKG. These are recommended for all procedures.

I accept I do not accept

  • Pre-Anesthetic Blood Profile
  • 4DX Test

I certify that I have read and fully understood the terms and conditions indicated here

Electronic Signature        Date

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