Countryside Companion Veterinary Services

7659 Old State Road,
Holly Hill, SC 29059

(803)496-5037

www.huttoveterinaryclinic.com

Surgery Authorization Form

Today's Date (required) :
Your Full Name (required)
First Name (required)
Last Name (required)
Patient Name (required)

Patient Breed (required)

Sex (required)
Male
Female
Unknown
High end of estimate (if you requested one):

Procedure(s) (required)


I would like these additional services performed while my pet is at the hospital (prices vary - we can provide an estimate). Courtesy nail trims are provided with every anesthesia:
Select from the following (NA if not applicable) (required)
Express Anal Glands
Ear cleaning
Heartworm test
Feline Leukemia/FIV Test
Annual Vaccines/Additional Vaccines (varies)
Medication refill (charges will apply)
Microchip
NA
Pre-operative blood work within past 30 days? (required)

Yes
No


I elect to have blood work performed in the clinic today. (required)

Yes
No


IV fluids during procedure: (required)

Yes
No


ANESTHESIA/SEDATION/PROCEDURE AUTHORIZATION

I understand that unforeseen conditions may be revealed during the procedures that may require more extensive or different treatments. I have chosen which diagnostics and procedures to be performed for my pet in relation to my pet's risk associated with anesthesia. I have been given an estimate and I recognize that an estimate is not a guaranteed cost.
Do you agree? (required)

YES
NO



I understand that I assume financial responsibility for all services rendered. I also understand that full payment is due when services are rendered.
Do you agree? (required)

YES
NO



I understand that I assume financial responsibility for all services rendered. I also understand that full payment is due when services are rendered.
Do you agree? (required)

YES
NO



I hereby authorize surgery/anesthesia for my pet. I understand that some risks always exist with anesthesia or surgery and include but are not limited to infection, cardiovascular disease, neurologic disease, disfigurement and rarely, death. I acknowledge these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I also understand that I have elected certain tests or procedures that will affect the risk associated with anesthesia for my pet. I will not hold Hutto Veterinary Clinic, the attending veterinarian, or any staff member liable for any complications that may arise.
Do you agree? (required)

YES
NO



If life-threatening complications do occur, I authorize the attending veterinarian/staff to do everything possible to maintain the health/life of my pet (perform CPR).
Do you agree? (required)

YES
NO


I will be available at (phone #): (required)
Phone TypePhone Number (required)
When did the patient eat last? (enter day & time) (required)

List any daily/chronic medications including dose and time: (NA if not applicable) (required)

IMPORTANT:
Hutto Veterinary Clinic is not a 24 hour medical facility. If your companion requires overnight hospitalization and you would like him/her to receive 24 hour care, we can set up the transfer to such a facility. You will be responsible for the transportation of your pet to the facility.
By selecting "I agree" below, you are confirming that all of the above information is true, and this selection qualifies as a digital signature. Do you agree to all of the above terms? (required)

I agree (signature)
I disagree



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