Patient Drop Off & Consent Form – Surgery

We will strive to keep charges in line with any estimate given, however, unforeseen situations may arise. If the need arises, we will inform you of any additional charges that may be required prior to performing the service. If we cannot reach you, and a procedure needs to be performed for the health and safety of the animal, it will be done, and charges will appear on your bill.

All pets that are admitted into the hospital are required to be current on all vaccinations, parasite checks and physical exams. All admitted pets must be free of external parasites. Animals with fleas or ticks present will be administered a preventative at the owner’s expense.

Pets that are hospitalized on an emergency basis will require a deposit for treatments based on an initial assessment. Extensive hospitalized stays may require keeping charges current prior to expected discharge.

Payment for all rendered services is due at the time of discharge.

We at the Bensenville Animal Hospital do all we can to ensure that your pet receives the safest and most up-to-date medical care. However, unforeseen complications can and do occasionally arise during or after a procedure. In the event my pet experiences a cardiac, respiratory, or other life-threatening emergency that requires resuscitative or other urgent care measures, such as cardiopulmonary resuscitation (CPR), emergency drugs, or other similar measures, I request that the veterinarians and/or trained staff at Bensenville Animal Hospital pursue treatment as indicated below. Please initial one of the two options:

Resuscitate: I authorize emergency treatment if the situation arises (including cardio pulmonary resuscitation (CPR) and other life-saving treatments) and understand this may result in additional charges and I agree to pay for these emergency and life-stabilizing treatments even if they exceed any estimate I may have been provided. I understand that despite the best efforts of veterinarians and staff at Bensenville Animal Hospital, any emergency treatment does not guarantee or assure a favorable outcome for my pet.

Do Not Resuscitate (DNR): I do NOT authorize emergency treatment if the situation arises (including cardio pulmonary resuscitation (CPR) and other life-saving treatments) and prefer to be contacted before any additional treatment is performed. I understand that this may result in the death of my pet.

I, the undersigned owner or agent of the owner, certify that I am eighteen years of age or over and authorize the veterinarian(s) at this practice to perform the above procedure(s). I understand that I am encouraged to discuss any concerns or questions about any medical risks with the doctor before any exam/procedure is/are initiated. I understand that medical treatments, including anesthesia, are not without risks. Your signature below signifies understanding of the above and authorizes the attending veterinarian to perform the procedures listed as well as any emergency treatment that may become necessary. Your signature also releases Bensenville Animal Hospital of any liability associated with the treatment of your pet both during and after service rendered.