Veterinary Anesthesia Form

Your pet is scheduled to undergo a general anesthesia procedure. Basic pre-anesthesia instructions are as follows:

1. Your pet may have access to water until 8am the day of the procedure.
2. Please give or send your pet's regular medications with them the morning of their procedure.
3. DO NOT FEED your pet the morning of the procedure. Be sure to take up any free-feed items when you go to bed the night before the procedure.

Please note, any cancellation of a scheduled anesthetic procedure without a minimum of 24 hours notice will incur a $50 cancellation fee.

Pet's Name*

First NameLast Name

Your Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

It is imperitive that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk.

Where can we call you at while your pet is here?*

Area CodePhone Number

Is there anyone else we can call regarding your pet while they are here today?

YesNo

Alternative Contact Name*

First NameLast Name

Alternative Contact Phone*

Area CodePhone Number

Reason for your pet's visit today?

If surgical, please list surgery type (i.e. Spay, Neuter, Dental Cleaning, Mass Removal etc.)

Has your pet had any food since midnight last night?

YesNoUnsure

Has your pet been vomiting or having diarrhea?

YesNoUnsure

Does your pet have any allergies?

YesNoUnsure

If yes, please describe/provide more information

Has your pet ever had any adverse reaction to medication?

YesNoUnsure

If yes, please describe/provide more information

Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given:

When Was Your Pet's Last Dose of Flea/Tick Preventative?

Date Given (Please type N/A if not on a preventative)

What Kind of Flea/Tick Preventative Do You Use?

Name of medication - put unknown if not sure

Please note: Orcas Veterinary Service will require that a treatment will be applied at the owner’s expense to any pet with evidence of fleas, flea dirt, or ticks.

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Is Your Pet Current On Vaccinations?

YesNoI Am Not Sure

My pet's vaccines were administered last by:

Orcas Veterinary ServiceI Am Not Sure WhereOther

Does Your Pet Have A Microchip?

YesNoI Am Not Sure

Do you want your pet microchipped today? (Additional Fees Apply)

YesNo

Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?

If yes, please tell us more. If no, please note N/A

Is There Anything Else We Should Know About Your Pet?

If yes, please tell us more. If no, please note N/A

Are there pictures or video that would help us with our exam today?

Browse Files

Please upload if available.

Is There Anything Else You Would Like To Discuss Today?

I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Orcas Veterinary Service. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.*

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I agree to recommended pre-anesthetic lab work. Please see your estimate for pricing details. If you decline this service, this may delay your pet's procedure.*

I agreeI decline this service even though it is against medical advice to do so. I accept the responsibility of my decision.

I agree to the recommended service of placing an IV catheter and administration of fluid therapy to my pet during the scheduled procedure. *Please see your estimate for pricing details.*

I agreeI decline this service even though it is against medical advice to do so. I accept the responsibility of my decision.

I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.*

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I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).*

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In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:*

Please proceed with cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred (starting range of $150-300).Please do not proceed with cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred.

I acknowledge my choice regarding resuscitation choice for my pet as noted above.

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Payment is required at time of service. A deposit may be required prior to your procedure. Our customer service team will contact you if this is the case. Otherwise, please select your preferred method of payment for this procedure:

I will pay the entire balance by Credit Card (3% Surcharge Added)I will pay with Care Credit (invoice balance must be greater than $500)I will pay the entire balance by check or cashI will enroll in a Payment Plan by VetBilling (3 or 6 month no interest financing with $25 enrollment fee and a minimum of 20% down. Please ask for details).

I acknowledge Orcas Veterinary Service's Financial Policy: Payment is required at time of service. No credit will be extended without enrollment into a payment plan. All balances over 30 days will be subject to a finance fee of no less than 5%. ALL balances not enrolled in a payment plan will be sent to collections at 90 days, no exceptions.

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Anesthesia Consent Form

Authorizations

Payment & Financial Policy Agreement