Pico Veterinary Hospital

Consent Form

Fill out our consent form below! Use the button to get started.

Pico Veterinary Hospital of Yorba Linda Consent Form

It is our mission to partner with our clients to nurture and preserve the human-animal bond by providing compassionate, expert, and affordable veterinary care from your pet’s first adventure throughout a long and healthy life. Please fill out the form below as accurately as possible.

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 Pico Veterinary 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 Pico Veterinary 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 *

Date *

Phone

Ready For A Visit?

We Look Forward to Seeing You Soon!

Pico Veterinary Hospital of Yorba Linda proudly delivers lifelong care for your pets in Yorba Linda, Placentia, Villa Park, Anaheim Hills, Olive, Orange Park Acres, Brea, and beyond.

Questions?

Get in touch! Complete our online form, and a member of our team will be in touch with you shortly.

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Location

23661 La Palma Ave
Yorba Linda, CA 92887

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Contact Information

P: 714-503-8928
F: 714-692-1820
E: [email protected]

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Hours

Mon-Fri: 8am – 6pm
Sat: 8am – 3pm
Sun: Closed

Name *

First

Last

Email *

Phone

How can we help you? *