Accepting new clients!

Please note: We are hiring Veterinarians and Veterinary Externs

Surgery Consent Form

Save time during your appointment! Complete your required form online from any device at any time before your visit.

Surgery Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet before your visit.

CLIENT INFORMATION

Owner Name *

First

Last

Phone Number *

Please enter a valid phone number.

Owner Email *

Owner DOB *

We may send home controlled substances for your pet’s pain, the state of Indiana REQUIRES pet owner date of birth and driver’s license number. You or the person picking up your pet will be asked for their drivers license upon picking up medications.

Driver License # *

PET’S INFORMATION

Pet's Name *

Please list any medications or supplements (Over the Counter or Prescription) with date and time last given:

Does your pet have any history of seizure activity? *

Any known medication allergies? *

If your pet needs dental extractions : *

Authorize all extractions without a call
Call before any extractions

Send for biopsy: *

Does your pet need any other below services while they are sedated? Note: There may be a charge associated with the services provided.

CLIENT’S CONSENT

I understand that my pet is undergoing anesthesia and a surgical, dental or other procedure listed on page 1. I have been informed of and accept the risks associated with the procedure. Anesthetic Complications: Although complications are rare, they can happen. Possible complications can happen before, during, and after anesthesia and surgery. Including but not limited to: vomiting, aspiration, swelling, infections, pain, decreased appetite, diarrhea, slow recover, and suture site reactions. Other rare complications of anesthesia include organ failure such as liver or kidney failure, visual impairment, clotting disorders/bleeding, seizures, allergic reactions/anaphylaxis, cardiac arrest and death, and other unexpected anesthesia reactions.

I Agree and Understand

Our veterinarians, nurses and staff will take every precaution to minimize risks during your pet’s procedure. You accept and understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. On the rare chance that your pet experiences a life-threatening event under anesthesia, your pet may need medical intervention, additional diagnostics including, stat blood work, radiographs and CPR. The cost estimate for this could run an additional $300-$900.

I Agree and Understand

I authorize all emergency diagnostics and treatments in the event of an emergency situation. I am providing phone numbers where I can be reached in the event of an emergency.

Decline
Approve

The undersigned hereby warrants that he/she is over the age of 18, the owner or authorized agent of the owner of the above-named animal, and does hereby request, consent and authorize St. John Animal Clinic to care for, treat or perform the procedures listed above.

I Agree and Understand

The undersigned further acknowledges that no guarantees have been made except reasonable precautions against complications, injury, escape, illness or death with the understanding that the undersigned will remain fully responsible for all costs of all services provided by St. John Animal Clinic. The clinic is not staffed 24 hours a day. The doctor may recommend the pet be transferred to an emergency clinic if 24 hour medical care is necessary.

I Agree and Understand

If I have received an estimate of costs for the proposed procedure. I understand that as the management of a case develops, additional treatment or course of action may be required, and the cost may exceed the original estimate. I will be contacted at that time if additional costs beyond 10% of the estimate are required. Inability to contact me does not alter my liability for the total charges of treatments required. A deposit of 50% of the estimated cost may be required. I also understand that additional charges for post operative care are not included in the estimate.

I Agree and Understand

I agree and assume all financial responsibility for all services rendered: Payment Policy; We accept cash, checks (with ID), Master Card, Visa, Discover, Cherry, and CareCredit for payment of services. Payment in full is required at time of discharge.

I Agree and Understand

By typing/signing below, I confirm that I have read, comprehend, and agree to the above outlined surgery or procedure and everything outlined in the surgical procedure consent form above.

Signature

Clear Signature

*Please allow 15-20 minutes for surgery admission time.

Website

Surgery Consent Form

Surgery Consent Form

CLIENT INFORMATION

PET’S INFORMATION

CLIENT’S CONSENT

By typing/signing below, I confirm that I have read, comprehend, and agree to the above outlined surgery or procedure and everything outlined in the surgical procedure consent form above.

We’re Excited to See You

Contact info

Address

Hours

After Hours Emergency

Contact info

Address

Hours

After Hours Emergency

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We Proudly Serve Pets of St. John, IN, and Beyond

Mon & Wed:	7:30am – 6:00pm
Tue & Thu:	9:00am – 6:00pm
Fri:	7:30am – 5:00pm
Sat:	7:30am- 12:00pm
Sun & Holidays:	Closed

Mon & Wed:	7:30am – 6:00pm
Tue & Thu:	9am – 6pm
Fri:	7:30am – 5pm
Sat:	7:30am – 12pm
Sun & Holidays:	Closed