Surgery Authorization Form

At Trinity Veterinary Medical Center, your pet’s safety and well-being are our top priorities. If your pet is scheduled for surgery or a procedure requiring authorization, please complete the Surgery Authorization Form prior to your appointment to help ensure clear communication and a smooth experience on the day of treatment.

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Surgery Authorization Form

This form allows us to obtain the necessary consent and information required to proceed with your pet’s scheduled surgery or procedure. Completing this form in advance helps our veterinary team prepare appropriately and ensures that all required authorizations are in place.

COMPLETE THE SURGERY AUTHORIZATION FORM

Surgery Authorization Form

Client Name *

First

Last

Patient Name *

Phone *

Email *

Anesthetic and medical or surgical procedure(s) to be performed:

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 this practice 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. 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 the fees for all services
Any necessary payment arrangements

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and 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, 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 (check one of the following): my permission to provide such treatment and I agree to pay for such services

HAS
DOES NOT HAVE

In the event my pet is hospitalized beyond the first day at this facility, I understand that veterinary care during nighttime hours and/or weekends is not provided on a continual basis. If I desire that my pet have supervision when this facility is closed, I elect to (check one of the following)

Pick up my pet and provide such care in my home, in which case I accept all risks of adverse effects
Make arrangements to transfer to a local emergency clinic where overnight veterinary supervision is available at my expense.

I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and give my consent to proceed.

Signature of Owner or Authorized Agent *

Clear Signature

Date *

Surgery Authorization Form

Surgery Authorization Form

Surgery Authorization Form

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