I certify that I am the owner or authorized agent for the above animal. I hereby consent to and authorize the doctors and staff at this veterinary practice to admit this pet, and administer anesthesia, surgical procedure(s) and the following procedures as checked above. I have been advised of the nature of the procedures and the potential risks and benefits. I understand that veterinary medicine is an inexact science and that no guarantee of successful treatment can be made.

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.