Consent Form

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Primary Phone Number

Secondary Phone Number

Pet Name

Gender

Procedure

Please type the name of the surgery you are consenting to

Please initial each bullet point and sign at the bottom of page to consent to the treatment for the patient listed above:

I declare that I am the authorized owner or agent of the animal listed above. I am 18 years of age or older and have the authority to consent to the medical and/ or surgical treatment listed above.

I authorize the medical and/ or surgical treatment listed above. This medical and/ or surgical treatment has been explained to me and all questions I have, have been answered.

I understand that there are risks of complications with the procedure(s), indicated in the treatment plan, including the possibility of death as a severe complication of surgery, anesthesia, or other procedures.

I also understand there is no guarantee to the results of the outlined procedures, diagnostics or treatments.

In the event of cardiopulmonary arrest (loss of normal heartbeat and breathing) I understand that I will be called to discuss options for my pet’s care. Until I can be reached, please select and initial ONE of the following:

Select ONE option:

I authorize CPR (Cardiopulmonary Resuscitation) as deemed necessary by the veterinarian.

I authorize a DNR (Do Not Resuscitate) order

Initials

I understand that any personal belongings (leash, collar etc.) left with my pet are not guaranteed to be returned to me and are not the responsibility of WCAEC.

I hereby certify that I have read and understood this treatment plan authorization, and I consent to treatment. I am signing this document voluntarily and without duress. I have been informed of the possible risks associated with this treatment plan.

OPTIONAL: I, the owner or agent of the patient described above, give consent to West Coast Animal Eye Care to use photographs, videos and social media postings of my pet on all WCAEC social media pages.

Today's Date

Year

Month

Day

Signature

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