Anesthesia Standard Consent Form

Owner's Name

Name of Pet

Email Address

I am the owner or agent for the owner of the animal describe above and I have the authority to execute the consent.

I herby consent and authorize the performance of the following procedure(s) or operation(s)

I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions or problems may become evident that necessitate an extension of the foregoing procedure(s) or operation(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) of operation(s) as are necessary in the exercise of the veterinarian’s professional judgement. I also authorize the use of appropriate anesthetics and other medications and I understand that hospital personnel will be employed as deemed appropriate by the veterinarian. I have been advised as to the nature of the procedure(s) or operation(s) and the risk involved. I realize the results cannot be guaranteed.

Has food/water been withheld since midnight last night? Has food/water been withheld since midnight last night? Yes No

*For the safety of all our pets as well as our personnel, all pets must be current on rabies vaccinations, if they are not, these will be administered while they are hospitalized.

We highly recommend your pet get a e-collar to prevent the pet from irritating the incision site. We highly recommend your pet get a e-collar to prevent the pet from irritating the incision site. Yes No

Do you want your pet microchipped today? Do you want your pet microchipped today? Yes No

Other than heartworm and/or flea prevention, is your pet currently on any medications? Other than heartworm and/or flea prevention, is your pet currently on any medications? Yes No

If yes, then what medications and when were they last given?

Pre-Anesthetic Blood Testing Consent Our greatest concern is the wellbeing of your pet. A pre-anesthetic blood profile is needed to maximize the patient safety and alert the doctor to the presence of dehydrations, anemia, infection, diabetes and/or kidney or liver disease that could complicate the procedure. The conditions may not be detected without a pre-anesthetic profile. In addition, the results of these tests may be useful if your pet’s health changes, serving as a baseline for comparison for future blood test. These are required for all patients over 7 years of age.

Bloodwork for patients 7 years or older Bloodwork for patients 7 years or older I accept the pre-anesthetic blood work required by the veterinarian.

Bloodwork for patients under 7 years Bloodwork for patients under 7 years I accept the pre-anesthetic blood work recommended by the veterinarian. Choose one of the following Pre-Op Screen, CBC ($65) Superchem/CBC ($120)

I decline the recommended pre-anesthetic blood work and request that you proceed with the anesthesia. I understand that there are always risks when using anesthesia or preforming surgery on an animal. I decline the recommended pre-anesthetic blood work and request that you proceed with the anesthesia. I understand that there are always risks when using anesthesia or preforming surgery on an animal. I decline

IV Fluids (to support blood pressure and circulation) Our greatest concern is the wellbeing your pet. An intravenous catheter will be placed for the safety of your pet. Intravenous fluids can be administered during anesthesia to help maintain blood pressure and allow administration of drugs should an emergency situation develop. IV Fluids (to support blood pressure and circulation) Our greatest concern is the wellbeing your pet. An intravenous catheter will be placed for the safety of your pet. Intravenous fluids can be administered during anesthesia to help maintain blood pressure and allow administration of drugs should an emergency situation develop. I accept the IV catheter I decline the IV catheter

Dental Extractions

With dental procedures there is always a possibility the pet will need extractions. The doctor will examine all teeth while the patient is under anesthesia and determine which, if any, teeth will require extractions. Simple or complex extractions may be necessary at an additional cost. With dental procedures there is always a possibility the pet will need extractions. The doctor will examine all teeth while the patient is under anesthesia and determine which, if any, teeth will require extractions. Simple or complex extractions may be necessary at an additional cost. I authorize extractions I decline extractions

Signature of Owner/Agent ( Type Full Name )

Date

Best phone number(s) where you can be reached today