*2021_Anesthesia/Procedure Consent Form
Thank you for entrusting to us the health of your pet.  We hope you and your family are staying safe and healthy.

Because of the safety precautions we have to implement in response to COVID-19, we request our clients to fill out this Form in advance. A part of our social distancing protocol is to primarily communicate with our clients by phone during the appointment. Your answers to the history form will further help us better understand what needs to be done with your pet as well as address other concerns that you may have.

We appreciate your kindness, patience, and cooperation.
Email address *
Full Name of Client and Pet's Name *
Budget Threshold *
In this time of COVID-19, we want to let you know that we are mindful of our client's budget. While we attempt to provide an approximate cost of our services, an estimate can easily change because every veterinary patient is different, and the corresponding care varies. Certain surgical procedures can have unforeseen problems/complications that significantly impact the veterinary care provided and consequently the cost. Please indicate the dollar amount of your budget threshold below and we will call you once your budget threshold is reached or if about to go over.
Patient History *
Please write here ALL the pertinent information that you want Dr. Elmar Zamora to know about your pet relevant to this appointment.
Mode of Payment *
Consent to Anesthesia/Procedure/Blood Test (if applicable) *
I acknowledge there may be concealed health risks to my pet and release A.E.Z.R. PET HOSPITAL and staff from liability from any unforeseen complications arising from anesthesia/surgery. I hereby authorize the admitting veterinarian or designated associates and assistants to perform diagnostic tests/procedures on my pet, as applicable. I confirm that the doctor/staff explained the procedure thoroughly to me and how it will help my pet with its current condition. I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups. I understand that anesthetic and surgical, diagnostic, or therapeutic procedures may involve risk of complications, injury, or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure.
CHECK-IN Client Health Disclosure *
If you are sick, or have fever, body aches, cough, etc., please have a family member or a friend bring in your pet.
Signature / Date Signed *
By typing my full name below, it constitutes my acknowledgment that I have provided information to the best of my knowledge.
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