Consent for Surgery Owner Information Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pet Information Pet Name * First Name Last Name Age * Sex * Male Female Color * Consent for Surgery * I understand that by entering my name, I hereby give Blue Barn Rescue authorization to have my pet undergo surgery at their discretion, with the veterinarian of their choice. I understand that there are risks to general anesthesia that may result in the death of my pet. I understand that there are risks of post operative complications that may result in the death of my pet. I will not hold Blue Barn Rescue or any of it's associates responsible in the event that complications or death of my pet should occur. I will not pursue legal action against Blue Barn Rescue or any of its associates in the event that complications or death of my pet should occur. Date MM DD YYYY Unforeseen Intra-operative Circumstances * In the event that my pet should experience cardiac arrest during surgery, I give consent to perform CPR and other life saving measures. I understand that there may be additional expense to receive additional medical care. I understand that I am responsible for the cost of additional services provided in order to attempt to save my pet's life. I understand that in the event that my pet does not survive despite life saving measures, I am still responsible for payment of additional costs incurred. Resuscitate Do Not Resuscitate Unforeseen Postoperative Circumstances * I would like my pet to receive emergency post operative medical attention if necessary. I understand that there may be additional expense to receive additional medical care. I understand that I am responsible for the cost of additional services provided in order to attempt to save my pet's life. I understand that in the event that my pet does not survive despite life saving measures, I am still responsible for payment of additional costs incurred. Yes No Thank you for submitting your surgical consent form.
