Henrietta Animal Hospital, PLLC

Procedures and Operation Consent / Release Form

Date ____/____/____  Owner’s Name___________________ Patient Name __________

I hereby authorize Henrietta Animal Hospital, its employees, representatives and all/any agents to receive, hospitalize, care for, vaccinate, prescribe for, mediate, test, bathe, sedate, anesthetize, and or operate upon my animal as they deem necessary for the health, safety, or well being of my pet.

I hereby authorize Dr. Brownstein and/or such assistants as may be selected by her to perform the following procedure(s): ____________________________ upon my pet.

The procedure(s) listed above have been explained to me and I understand the nature, consequences, or possible consequences and risks of the above procedure(s).

I recognize that during the course of the procedure, unforeseen conditions may necessitate additional or different procedures than those set forth above. I further authorize and request that the above named surgeon, vet assistants, or her designees perform such procedures as are n her professional judgment necessary or desirable.  The authority granted under this paragraph shall extend to remedying conditions not known to the above named surgeon at the time the operation is commenced.

I consent to the administration of anesthesia to be applied by or under the direction and direct supervision of Dr. Michelle Brownstein and to the use of anesthetics, as she may deem advisable.

I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me as to the results of the operation or procedure. I have been made aware of the risks and consequences that are associated with the procedure(s) described in paragraph 1.

I understand that there will be an additional charge if my cat or dog is in heat, pregnant, or post puberty.

Pre-operative lab work is mandatory for all animals over 6 years of age.  See enclosed sheet.

 I have read the above and understand and consent to its contents:

Signed ________________________________________ Phone # _____-_______-_____