Anesthesia and Surgery Form

subpage divider

Authorization for Anesthesia and Surgery

Authorization for Anesthesia and Surgery

Name
Name
First
Last
I, the undersigned owner or agent of the owner of the pet identified above certify that I am eighteen years of age or over and authorize the veterinarian(s) at Prince William Animal Hospital to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.
I give my permission for Home Again Microchip for permanent identification

My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

The reasonable medical and/or surgical treatment options for my pet

  • Sufficient details of the procedures to understand what will be performed
  • How fully my pet will recover and how long it will take
  • The most common and serious complications 
  • The length and type of follow-up care and home restraint required
  • The estimate of fees for all services
While I accept that the procedure will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.
I agree to assume financial responsibility for the fees, and provide payment via cash, credit card, care credit, or check at the time my pet is discharged from the hospital.
Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services.
By signing below, I am confirming that I have read and fully understand the terms and conditions set forth above.
cat scratching post circle

If you have any questions, give us a call at (703) 361-5223

teal underline