Authorization Form

Click here for the PDF version of this form.

I am the owner or the authorized agent for the owner of:

Patient Name*

Breed

Color

Age

Sex
MaleFemaleSpayed/Neutered

Known allergies

Adverse reactions to medications or anesthetics

and as such I have the authority to execute this consent.

I hereby give Matthew Nicholson, DVM, DACVS, CCRP, Salutaris Veterinary Specialists, PLC, and any authorized agents, staff or representatives consent and authority to perform the following procedures or operations as they have been discussed:

Surgical Procedure*

Please specify which limb(s) if indicated

The nature and purpose of these operations or procedures, risks involved, and possibility of complications have been fully explained to me. I have been informed that there are certain inherent risks and complications associated with any operation or procedure including but not limited to anesthetic related risks, bleeding, infection, and even death.

I further understand that during the course of the operations or procedures unforeseen conditions may arise that may necessitate the performance of additional procedures or operations. Therefore, I hereby consent and authorize the performance for such procedures or operations as are necessary and desirable in the exercise of the veterinarian’s professional judgment.

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 treatment or examination in the hospital.

I authorize the use of appropriate anesthesia and pain relief medications as needed before and after the procedure. I have been informed that there are risks associated with the use of any medication.

I understand that hospital support personnel will be used as deemed necessary by the veterinarian on duty.

Name*

Date*