INTERNATIONAL CENTER FOR VETERINARY SERVICES 北京新天地国际动物医院 SURGERY/ANESTHESIA CONSENT FORM 同意手术书
PATIENT FILE NO.病例号__________________PATIENT NAME病例名字________________________ SPECIES种类____________________________ BREED品种______________________________________ DATE OF BIRTH出生日期_____YY年_____MM月_____DD日GENDER性别 □Male雄 □ Female雌 NEUTERED/SPAYED节育 □Yes 是 □No否 OWNER畜主_______________________________TEL 电话_______________________________________ ADDRESS地址______________________________________________________________________________ PROCEDURE手术种类______________________________________________________________________ VETERINARIAN兽医签字_______________________________________________________ SURGERY/HOSPITALIZATION DATE 手术／住院日期: ________YY年_______MM月_______DD日 I hereby consent and authorize the International Center for Veterinary Services to administer anesthesia, perform diagnostic and surgical procedures and prescribe for the above described pet. These procedures and operations may all involve risks of unsuccessful results, complications, or even fatalities from both known and unforeseen causes and no warranty or guarantee is made as to the result or cure. I have discussed with the veterinarians or their designated associates or assistants the nature and purpose of the procedure or operation and the available alternative methods of treatment and have received and understood all the information I desire regarding said procedures of operations. I also understand that it may be necessary to provide emergency medical care. In the event that I cannot be contacted, I authorize the International Center for Veterinary Services or the designated emergency clinic to render such care. I accept financial responsibility for the treatment of the above described pet and I understand that full payment of the estimate prior to surgery and hospitalization is required. Any additional charges that arise after payment of the initial estimate will be settled prior to release from hospitalization or when service is otherwise terminated. 我授权兽医对我的宠物（犬、猫等）进行这张表格所填写的相关治疗，包括麻醉等一切兽医考虑到对动物治疗有用及必要的方式。同时, 我完全明白任何手术均存在着潜在不可预料因素及风险。上述不可预料因素，风险及后果北京新天地国际动物医院的医务人员均已告知本人。因此本人认可并同意如在手术中发生意外情况甚至死亡，与贵院及手术人员无责。并在手术前预付兽医所预估的全部治疗费用(多退少补)。 Authorized signature 畜主签名:_________________________ Date日期 YY年 MM月 DD日

INTERNATIONAL CENTER FOR VETERINARY SERVICES

北京新天地国际动物医院
SURGERY/ANESTHESIA CONSENT FORM
同意手术书

PATIENT FILE NO.病例号__________________PATIENT NAME病例名字________________________
SPECIES种类____________________________ BREED品种______________________________________
DATE OF BIRTH出生日期_____YY年_____MM月_____DD日GENDER性别 □Male雄 □ Female雌 NEUTERED/SPAYED节育 □Yes 是 □No否
OWNER畜主_______________________________TEL 电话_______________________________________
ADDRESS地址______________________________________________________________________________
PROCEDURE手术种类______________________________________________________________________
VETERINARIAN兽医签字_______________________________________________________
SURGERY/HOSPITALIZATION DATE 手术／住院日期: ________YY年_______MM月_______DD日

I hereby consent and authorize the International Center for Veterinary Services to administer anesthesia, perform diagnostic and surgical procedures and prescribe for the above described pet. These procedures and operations may all involve risks of unsuccessful results, complications, or even fatalities from both known and unforeseen causes and no warranty or guarantee is made as to the result or cure. I have discussed with the veterinarians or their designated associates or assistants the nature and purpose of the procedure or operation and the available alternative methods of treatment and have received and understood all the information I desire regarding said procedures of operations. I also understand that it may be necessary to provide emergency medical care. In the event that I cannot be contacted, I authorize the International Center for Veterinary Services or the designated emergency clinic to render such care. I accept financial responsibility for the treatment of the above described pet and I understand that full payment of the estimate prior to surgery and hospitalization is required. Any additional charges that arise after payment of the initial estimate will be settled prior to release from hospitalization or when service is otherwise terminated.

我授权兽医对我的宠物（犬、猫等）进行这张表格所填写的相关治疗，包括麻醉等一切兽医考虑到对动物治疗有用及必要的方式。 同时, 我完全明白任何手术均存在着潜在不可预料因素及风险。上述不可预料因素，风险及后果北京新天地国际动物医院的医务人员均已告知本人。因此本人认可并同意如在手术中发生意外情况甚至死亡，与贵院及手术人员无责。并在手术前预付兽医所预估的全部治疗费用(多退少补)。

Authorized signature 畜主签名:_________________________

Date日期 YY年 MM月 DD日