Authorization Form - Lumpectomy

THANK YOU for choosing our Hospital! Please feel free to contact us if you have any questions regarding any of our services. IMPORTANT: Service dates and arrangements are not confirmed until you have received notification. A staff member will contact you by phone or email.

Authorization - I Am Authorizing The Following Procedures: Blood Work, IV Fluids, General Anesthesia, Lumpectomy, Antibiotic Injection, Analgesic Injection, Nail Trim, Possible Medication To Go Home.*
- Accept
- Decline
IF YOU CHOOSE DECLINE PLEASE DO NOT FILL OUT THE FOLLOWING FORM AND CALL OUR HOSPITAL.
Name*
First Last
Email*
Phone*
Pet Name*
Has your pet been here before?*
- Yes
- No
Please fill out any Comments or Special Instructions below: (Request for additional veterinary services, etc.)
Drop off Date*
Date Format: MM slash DD slash YYYY
Drop off Time - Must Be Between 7a.m. - 9a.m.*

: HH

MM
I can be contacted at anytime during the day of the procedure at the following number:*
First Last
Phone*

The nature of such services has been described to my satisfaction, and while I accept all procedures to be done to the best abilities of the professional staff, I realize that no guarantee nor warranty can ethically or professionally be made regarding the results or cure.

I hereby authorize OAK ANIMAL HOSPITAL or its representatives to perform such diagnostic, therapeutic, anesthetic and surgical procedures as are in the best opinion of my pet’s attending veterinarian, necessary while my pet is under sedation/anesthetic for treatment and maintenance of my pet’s health and well being.

There is a reduced risk of surgical complications due to advances in anesthesia, monitoring and pre-surgical blood work. I fully understand that there are always risks of anesthetic complications during any surgical procedure including death.

Any estimate of fees to be encured for presently planned procedures is only a best approximation. The final bill may fluctuate from this amount. Follow up charges such as further examinations, radiology, medication, or charges for unforeseen complications are not included in this estimate. I understand that I assume financial responsibility and will pay for all services upon the above named pets discharge from the clinic.

In the event of abandoning my pet, I hereby authorize OAK ANIMAL HOSPITAL or its representatives to surrender my pet to the S.P.C.A. five days after written notice of such abandonment has been sent to the owner’s address on record.

SIGNATURE:_______________________ DATE:_____________________

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