High Risk Waiver Form

Owner Name *

First

Last

Email *

Pet's Name *

Preferred Veterinary Clinic *

that always exist

Pre-Existing Medical Conditions

I, as the Owner/Agent, understand that some risks always exist with surgery and anesthesia, and that these findings indicate that the animal may be at an increased risk for surgery and anesthesia. *

I understand / agree to terms

This may represent an increased surgical or anesthetic risk, but the veterinarian is willing to proceed with surgery if you so choose.

By signing below, I, as the Owner/Agent, acknowledge that the Hines Veterinary Group staff has informed me of the increased risk to my animal as a result of the condition(s) identified above, and I understand and agree to accept these risks and/or forgo recommendations for pre-surgical diagnostic,s and I have chosen to proceed with surgery today.

By doing so, I acknowledge that any additional issues, complications, or costs associated with proceeding with this anesthesia and/or surgery are my responsibility.

I accept that no guarantee of successful treatment has been made. All questions and concerns I have about the risk posed to my animal have been answered to my satisfaction.

Owner Signature *

Clear Signature

Date *