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Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

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Pet Information

Pet's Name *

Contact Information

Owner's Name *

First

Last

Email *

Phone *

Additional Phone

Secondary Contact: *

First

Last

* This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

Secondary Contact Phone *

Today's procedure is: (example: lump removal, exam, etc.) *

Additional Services Desired While Patient Is Sedated

Please select any/all that you would like us to provide while your pet is sedated

Implant Microchip
Nail Trim
Clean Ears
Express Anal Glands
Sanitary Clip (rectum, genitals)
Remove Lumps (specify location of lumps below)
Other (specify below)

Please specify where the lumps are located *

Please specify the additional service(s) you'd like provided to your pet *

Authorization

I authorize anesthesia/sedation for my pet. The nature and risks of this procedure have been explained to me. I understand some risks always exist with anesthesia and/or sedation, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any questions have been answered to my satisfaction. *

I have read, understand, and authorize

I authorize Fairview Animal Hospital to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical complications or otherwise unforseen circumstances. I understand there are rare complications associated with any anesthetic procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks and understand the veterinarians and hospital staff will try to minimize such risks. I will not hold Fairview Animal Hospital, the veterinarians, or any staff member liable for any complications that may arise. *

I have read, understand, and authorize

Payment due upon services rendered. *

I have read, understand, and agree.

I HAVE READ AND FULLY UNDERSTAND THIS ANESTHESIA CONSENT FORM *

Signature of Responsible Party *

Clear Signature

Date *

Comment

We’re excited to see you.

We proudly serve the pets of Maryville, TN, and the surrounding communities. We look forward to seeing you and your pet soon. Easily book an appointment for your pet below.

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Have a question?

If you would like to get in contact with us by email for general questions or to request information on our services, please use the form below. We will attempt to respond to every email in a timely manner.

Address

2648 US Hwy 411 South Maryville,
TN 37801

Contact

P: 865-379-8833
E: clientcare@fairviewvethospital.com

Hours

Monday – Friday: 7:30 AM – 5:30 PM
Saturday: 8:00 AM – 1:00 PM
Sunday: Closed
Drop-offs begin at 7:40 AM – 9:00 AM

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Email *

Phone

How can we help you? *

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