Surgical and Drop-off Patient Forms

For Surgical/Observation Patients

* Indicates required field

Pet Name *

Owner Name(s) *

First

Last

Name *

First

Last

Best Phone Number *

Alternate Phone Number *

Email *

Virginia Veterinary Hours Disclosure Form
Mt. Pleasant Veterinary Clinic has business and medical staffing hours as follows:
Monday, Tuesday, Wednesday & Thursday: 8A-6P
Friday: 8A-5P
Saturday: 8A-1P
CLOSED Sundays and holidays

This notice is to inform you that Mt. Pleasant Veterinary Clinic does not have on-duty medical staff care during the following hours:
Overnight: from closing time until 8am the following workday
Monday 6P-Tuesday 8A
Tuesday 6P-Wednesday 8A
Wednesday 6P-Thursday 8A
Thursday 6P-Friday 8A
Friday 5P-Saturday 8A
Weekend: from closing time at 1pm on Saturday until 8am Monday
Holidays: from closing time before the holiday until 8am the next workday.

I certify that I am aware of the staffing hours. Name: *

First

Last

Anesthesia / Surgical / Drop-off Consent.

Procedure(s) to be performed: *

I, the undersigned owner or agent of the pet identified above, authorize the staff of Mt. Pleasant Veterinary Clinic to perform the above procedure(s).

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 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 has my permission to proceed with life sustaining procedures. Name or "Don't Agree" *

First

Last

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 radiographs, 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.

A complete physical exam will be performed on your pet prior to the surgical procedure if it has been longer than 30 days since the last exam. However, this may not identify all systemic or metabolic problems. For this reason, your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia.

I have read and fully understand the terms and conditions set forth for payment, warranties, and exams. Name: *

First

Last

Submit