West Ridge Animal Health Center
2147 SW Westport Drive
Topeka, KS 66614

Even though this is online please make sure you have a few minutes to visit with the WRAHC team when you leave your pet!

Client Name*

Pet's Name*

Client's Email*

Client’s Address*

City, State, Zip*

Anesthetic and Medical/Surgical procedure to be performed:

I, the undersigned owner or agent identified above, authorize the team at West Ridge Animal Health Center to perform the above procedure(s). I certify that I am eighteen years or age or older and have the authority to make the decisions for above listed pet’s healthcare.

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.

I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life sustaining procedures (please select one below).

I give my permission for WRAHC to perform life sustaining procedures up to the amount of $300. (Yes)I do not give my permission for WRAHC to perform any life sustaining procedures that will be at additional cost, without contacting me first. (No)

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.

I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions.

I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein.


By typing my name below, I acknowledge that I have read and fully understand the terms and conditions set forth above.


Signature of the Owner/Authorized Agent


Phone number that that we can contact you on the day of surgery: