White Glove Service

In the interest of everyone’s safety, we are currently operating 100% curbside. Our White Glove Service provides the same excellent care to your pets, the difference is we are not allowing clients inside our building at this time. When you arrive at our center, please call us at 717-599-4259 and our team will provide you instructions for the next steps.

Anesthesia & Surgery Consent Form

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Please complete this form before your visit.

Today's Date *

Owner's Name *

First

Last

Phone *

Email *

Patient's Name *

This is a consent form to review the medical and financial aspects of procedures performed on my pet at Harrisburg Regional Veterinary Surgical Specialty.

I hereby give permission to Dr. Phil Zeltzman to perform the following diagnostic, anesthesia and/or surgery procedure(s):

Side of surgery *

Left
Right
N/A

Surgery being performed *

In the event of an emergency situation before, during, or after sedation, anesthesia, and/or surgery, I give Dr. Zeltzman and/or my pet’s veterinarian permission to do what is necessary to try to save my pet, including CPR (Cardio-Pulmonary Resuscitation). I understand there may be additional costs.

Signing on the line below means that I DECLINE CPR to be performed on my pet if it is ever needed.

Signature to DECLINE CPR

Dr. Zeltzman occasionally features patients on Facebook, YouTube, other social media sites, and in publications (print or online). With your permission, he may share your pet's picture, video, or story. He may mention your pet’s name, but never yours. While he can't offer compensation, he is grateful that you'll be helping other pets by educating pet owners & vets.

Signature to DECLINE social media

I was explained that Nocita, a local injection that can relieve pain for up to 3 days, may be used in my pet (if applicable). I understand there is a $200 fee to use Nocita.

Signature to DECLINE Nocita

I understand the purpose, success rate & possible complications of the above procedure(s). I accept that veterinary medicine is not an exact science, & that no guarantee of successful treatment has been made.

I hereby consent and authorize the doctor and nurses at Harrisburg Regional Veterinary Surgical Specialty to receive, hospitalize, prescribe for, treat, or operate on my pet. I understand there are risks associated with any anesthesia or surgery and that it may be necessary to provide additional medical treatments that are not anticipated.

I authorize the performing of such altered and/or additional procedures as are deemed necessary in the surgeon's professional judgment for the health and safety of my pet. I agree to be responsible for all charges incurred and provide full payment before my pet is discharged.

Owner’s signature (over 18 years of age) or agent *

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White Glove Service

Anesthesia & Surgery Consent Form

Please complete this form before your visit.

We help your pet get back to feeling their best.

Harrisburg Regional Veterinary Surgical Specialty is the first and only local veterinary surgery center in the Harrisburg area. We partner with your family vet to provide your pet with surgical expertise in orthopedic, “soft tissue” and cancer surgery. All we do is surgery!

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