Anesthesia / Surgical Authorization Form- Easton

Anesthesia / Surgical Authorization Form
Easton Animal Hospital staff ask that you please wear a mask when we interact with you at your car as we are helping bring in and return your pet to you. It is so imporant that we stay healthy so we can continue to help you and your pet.
Client Name: *

First Name Last Name
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number: *

Area Code Phone Number
Email you would like us to have for your pets reminders. *
example@example.com
Patient Name: *
Species: *
Breed: *
Is your pet: *

Female Male Unknown
Is your pet: *

Spayed/Neutered Intact Unsure
Primary Color: *
What surgical procedure is your pet scheduled for? *
Please let us know when this surgery is scheduled below: *

Month Day Year
Date
Since your pet is getting a full physical today, are there any questions or concerns that you would like to doctor to address?
At your surgery check-in, we will go over options of bloodwork, placing an IV catheter, and running fluids throughout the procedure.
To minimize some of the risks that are involved in surgery, please answer the following questions:
When did your pet eat last? *
Is your pet on monthly heartworm preventative? *

Yes No
Please list all medication, dosage, frequency, and time last dose given: *

Anesthetic and Surgical Procedures to be Performed
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. Since no anesthetic or surgical procedure is trivial or routine, we assure you that your pet will receive a full physical examination prior to anesthesia, and that he/she will be monitored before, during and after the procedure. Regardless of age or health, anesthesia and surgery present a small but real risk to your pet. The doctors choose the safest anesthetic drugs, monitoring equipment and personal attention to minimize these risks as much as possible. *

I understand and agree
CPR Consent:

Should my pet require CPR (Cardiopulmonary Resuscitation), including but not limited to cardiac compressions, positive respiration, emergency medications, or other heroic interventions, I consent that the doctors at Easton Animal Hospital are given my permission to conduct such medical care.

I also understand the following:
- I agree to be financially responsible for all veterinary services provided to my pet while Easton Animal Hospital team members pursue treatment.
- I understand that regardless of my pet’s recovery or survival I agree to pay the CPR fee in addition to other fees already identified by the practice and agreed upon by me.
- I understand that despite the best efforts of the doctors and team members, CPR may not be successful.
Please choose one of the following: *
Microchip Implantation: *

Yes, I want and authorize a microchip implantation No, I do not authorize a microchip implantation No, my pet already has a microchip
Microchip number:
By typing my signature on the bottom of this page, I understand this to be my expressed and written consent for anesthesia and surgical procedures on my pet. *

Clear
Date *

Month Day Year
Date
COVID-19 Acknowledgement
For the protection of both our team and clients, have you been exposed to COVID-19 or showing signs/experiencing symptoms of COVID-19 in the last 14 days? *

Yes- we can still perform surgery on your pet, please give us a call No
Have you traveled outside the United States of America or the state of Ohio within the last 2 weeks? *

Yes No
You may leave your pets leash, collar, and/or harness on and we will apply our slip leash as well when bringing your dog into the hospital. All cats and pocket pets must be in a carrier for the staff to bring your pet into the hospital.
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Anesthesia / Surgical Authorization Form

Anesthetic and Surgical Procedures to be Performed

COVID-19 Acknowledgement