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Client Consent Form

Ensure your pet receives the best surgical care by completing our detailed client consent form online.

A Corgi dog standing indoors with its toys

Client Consent Form

Before your pet’s surgery, please carefully read and complete the client consent form. Your understanding and authorization are essential to ensure the best care.

Date *

Name *

First

Last

Email *

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Patient's Name *

Referring Hospital *

Attending Veterinarian *

First

Last

Surgery To Be Performed: *

Consent and Authorization: I, the undersigned owner or agent of the owner, hereby consent to authorizing Dr. W. Wesley Kimberlin to perform the surgical procedure(s) listed above. I have discussed the listed surgical procedure(s) and the importance of pre-surgical diagnostics, such as bloodwork and radiographs, with the referring veterinarian. The referring veterinarian and the referring hospital will be performing the administration of anesthesia and monitoring as necessary. I understand that during the procedure, unforeseen conditions may arise, and they may necessitate an extension or variance in the procedure(s) or additional treatments. I authorize Dr. Kimberlin and/or the referring veterinarian, along with their assistants, to perform any additional or different procedures that are necessary or advisable in their reasonable discretion for my pet’s health and well-being. *

Yes, I agree.
No, I do not agree.

Acknowledgment of Risks and Complications: I understand that all procedures and anesthetic protocols carry inherent risks, including but not limited to infection, hemorrhage, swelling, bruising, implant failure, allergic reactions, or even death. I understand that complications may require additional diagnostics and surgery at an additional cost. I have discussed these risks with the referring veterinarian and/or Dr. Kimberlin, and I understand the potential complications that may arise. I accept these risks and consent to proceed with the surgery. *

Yes, I agree.
No, I do not agree.

Post-Operative Care: I understand the importance of post-operative care, and I will follow the instructions provided by the veterinary staff for the care of my pet after surgery. I agree to return for follow-up visits as directed, and I agree to contact the referring veterinary hospital immediately if any post-operative complications arise. I understand that failure to follow post-operative care instructions and/or failure to attend follow-up visits can result in the likelihood of the risks set forth above increasing in probability. *

Yes, I agree.
No, I do not agree.

Authorization and Release: By signing below, I acknowledge that I have read and fully understand this consent form. I have had the opportunity to ask questions, and I have received satisfactory answers. I voluntarily give my consent and authorization for the above-named procedure(s) to be performed by Dr. Kimberlin and the referring veterinary hospital staff. *

Yes, I agree.
No, I do not agree.

Do we have your permission to share your pet’s picture, video, or story? *

Pet Owner/Agent Signature *

Clear Signature

Date *

Phone Number You Can Be Reached at Today *

Signature of Witness for Phone Consent *

Clear Signature

Date *

Printed Name of Witness *

First

Last

Signature *

Clear Signature

Client Consent Form

Client Consent Form

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