Minor Home Procedures Consent Form for Mobile Vet Services

Name

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Procedure *

MM

DD

YYYY

When is the last time the pet ate? *

MM

DD

YYYY

Time *

Hour

Minute

Second

AM PM

I understand that unforeseen conditions may be revealed during the identified procedure(s) which, in the opinion of the attending veterinarian, may require more extensive or different procedures or treatments. I understand that reasonable efforts will be made to contact me to explain these procedures and treatments and obtain instructions regarding them. However, if the efforts are unsuccessful, I authorize performance of any life sustaining procedures or treatments, which are in the professional opinion of the attending veterinarian. I do hereby give the Veterinary Home Care Services, and such assistants as may be selected by them, complete authority to perform the above procedure(s), which I understand, or which have been explained to me. If I have not been informed regarding the above procedures to my satisfaction or do not understand, it is my responsibility to inquire at the time of signing this document. *

Yes, I give my permission.

No, I do not give my permission.

I, [Client named above], understand that for procedures involving general anesthesia or prolonged and/or deep sedation, it is standard practice to have a designated anesthetist—separate from the veterinarian or veterinary technologist performing the procedure—monitor the patient. This role is typically filled by a registered veterinarian or a registered veterinary technologist under the supervision of the veterinarian, ensuring the highest level of care and safety. However, I acknowledge that in certain exceptional circumstances, the veterinarian may determine that the procedure must proceed without an available designated anesthetist. I have been informed that this decision significantly increases the risks associated with the procedure, including but not limited to, inadequate monitoring of vital signs, delayed response to emergencies, and increased potential for complications during and after the procedure. Despite these increased risks, I hereby give my informed consent for [Pet named above] to undergo the [Procedure named above] without a dedicated anesthetist present. I fully understand the risks involved and agree to proceed with the procedure as recommended by Dr. Matthew Hejazi of Veterinary Home Care Services. I have had the opportunity to ask questions about the procedure, the increased risks due to the absence of a dedicated anesthetist, and any other concerns. I am satisfied with the explanations provided and accept the associated risks. *

I have read and agree.

No, I do not give my permission.

Date Signed

MM

DD

YYYY