Anesthetic Procedure Consent Form

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Pet's Name*

How would you prefer we contact you when the procedure is completed and your pet is waking up?*

Text: Same number as aboveText: Different number. Enter belowCallOther

I consent and authorize the performance of the following procedure(s):*

Additional Services:*

I would like my pet to have a complimentary pedicure while under anesthesiaI would like my pet to have anal sacs expressed (additional cost of $27.86) while under anesthesia.I would like my pet to receive a Home Again Microchip (additional cost of $62.34, including registration) while under anesthesia.None

All surgical patients receive intra-operative pain relief, which lasts for several hours and post-operative pain management, which ensure that healing will occur at the maximum rate possible. I understand my pet is here today for a procedure that may/will require general anesthesia. In order for anesthesia to be as safe as possible, I understand that a physical exam will be performed. I understand that my pet must have healthy blood-work results within the last 30 days. I understand that if my pet has not had blood-work performed in the last 30 days, pre-anesthesia blood-work will be done today to evaluate internal organ function and minimize the possibility of anesthesia complications. I understand that during the performance of the foregoing procedures, unforeseen conditions may be revealed that require additional treatments that those specifically listed above. If such procedures are necessary in the veterinarian’s professional judgment, I consent to the performance of these procedures as well. I understand that all patients will be examined for flea and/or tick infestation before surgery, and that if needed my pet will be treated at my expense. I have also been advised as the nature of the procedures and the risks involved. I realize that results cannot be guaranteed. I have read and understand this authorization and consent.*

I understand and approve sedation or anesthesia for my petI do not approve sedation or anesthesia for my pet

Signature*

Please verify that you are human*