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Vet Eye Specialists in Charleston, SC
Charleston Animal
Consent Form
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Charleston Animal Eye Specialists
Consent Form
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Client name
*
First
Last
Patient name
*
Email
*
Phone number at which owner can be reached today:
*
Additional number
After procedure:
Would you like us to text you after the procedure, or would you prefer a call?
*
Text
Call
Surgical procedure(s) to be performed:
*
Please select which eye will be receiving surgery:
*
Right eye
Left eye
Both eyes
I, the undersigned owner or agent of the pet identified above, authorize the staff of Charleston Animal Eye Specialists to perform the above procedure(s).
*
I have read and agree
Have you given your pets any medications or supplements in the past week?
*
Yes
No
Please list all medications and/or supplements:
When was the last time fed?
Any other concerns or allergies?
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.
*
I have read and agree
I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life sustaining procedures.
*
I give my permission [yes]
I do not give my permission [no]
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above.
*
I have read and agree
Signature
*
Clear Signature
Date
*
Email
Submit
