Rescue Forms

Rescue Forms

Rescue Forms

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WEIR VETERINARY SERVICES

RESCUE SURGICAL & ANESTHETIC CONSENT FORM

Rescue Name:
Pet’s Name:
Date of Surgery:
Owners Name:
Breed:
Sex:
Age:
Weight:
Color:
Please check (√) all that apply:
is due for vaccinations, to be administered today
first vaccine (ie; vaccinations will require booster(in 4 weeks))
is/may be pregnant; please proceed with spay at additional costs
has been fasted for 12 hours prior to admittance
microchip
additional request for services as listed below:

I hereby authorize the veterinarians and staff of Weir Veterinary Services to use anesthetics and medications.

The Rescue Agency agrees to pay, in full, for all checked off services as listed above.

Please list services NOT to be billed to the Rescue Agency, but to be billed to:

The possibilities, outcomes and risks have been explained to me.

I have read and understood this authorization and consent.

E-Signature / Name of Rescue Agent (please print): *
Date: *
Phone number(s) where Agent (s) can be reached today:
Pet to be picked up upon discharge today by:
roya