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Standard Consent Form – Bayside Animal Hospital
Please use the standard consent form below prior to your pet’s procedure.
Standard Consent Form
About You
Your Name
(Required)
First
Last
Spouse Name
First
Last
Your Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Email
(Required)
Phone
(Required)
Cell Phone
Mailing Address (if different from above)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Pet's Name
(Required)
Name
Species
(Required)
Cat
Dog
Other
Gender
(Required)
Male
Female
Breed
Age/Date of Birth
If you cannot be reached when your pet is under anesthesia
(Required)
Perform whatever procedures are needed. I understand I am financially responsible for the cost of the added on procedures.
Do only the procedure I have authorized prior to leaving the facility.
I am:
(Required)
The pet’s owner
Authorized representative of the pet’s owner
Extra services that can be performed when your pet is under general anesthesia
Nail Trim $22.00
Nail Grind $36.00
Microchipped $75.00
Your Comments/Questions
I HEREBY GIVE BAYSIDE ANIMAL HOSPITAL AND ANY AUTHORIZED AGENTS, STAFF, OR REPRESENTATIVES CONSENT AND AUTHORITY TO PERFORM THE FOLLOWING PROCEDURES OR OPERATIONS:*
(Required)
I agree to all Bayside policies, per my selections and the information provided above.
THE NATURE OF THESE OPERATIONS OR PROCEDURES HAS BEEN EXPLAINED TO ME, AND I UNDERSTAND WHAT WILL BE DONE.I HAVE ALSO BEEN INFORMED THAT THERE ARE CERTAIN RISKS AND COMPLICATIONS ASSOCIATED WITH ANY OPERATION OR PROCEDURE OF THIS TYPE. THEY HAVE BEEN EXPLAINED TO ME AS WELL. I FURTHER UNDERSTAND THAT DURING THE COURSE OF THE OPERATIONS OR PROCEDURES, UNFORESEEN CONDITIONS MAY ARISE THAT MAY NECESSITATE THE PERFORMANCE OF ADDITIONAL PROCEDURES.I AUTHORIZE THE USE OF APPROPRIATE ANESTHESIA AND PAIN RELIEF MEDICATION AS NEEDED BEFORE OR AFTER THE PROCEDURE. I HAVE BEEN INFORMED THAT THERE ARE RISKS ASSOCIATED WITH THE USE OF ANY MEDICATION.I UNDERSTAND THAT HOSPITAL SUPPORT PERSONNEL WILL BE USED AS DEEMED NECESSARY BY THE VETERINARIAN.I AM THE OWNER OF THE ANIMAL DESCRIBED ABOVE, AND I HAVE THE AUTHORITY TO EXECUTE THIS CONSENT. I CERTIFY THAT IF I AM SIGNING AS THE AUTHORIZED AGENT FOR THE OWNER OF THE ANIMAL DESCRIBED ABOVE, I HAVE THE AUTHORITY TO EXECUTE THIS CONSENT.TREATMENT: IF FURTHER PROBLEMS ARE DETECTED WHILE YOUR PET IS UNDER ANESTHESIA, WE WILL ATTEMPT TO CONTACT YOU TO DISCUSS TREATMENT (FOR EXAMPLE, TOOTH EXTRACTION, LIPOMA TO BE REMOVED, ETC).
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