Anesthesia and Surgical Consent Form

Anesthesia and Surgical Consent

(360-794-6772)
Please thoroughly read, review, and complete form.
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Patient Name:*
Patient Species:*
Procedure to be performed:*
Hospitalization/ Surgical Information:

1. IV catheter: For most surgical procedures, an intravenous catheter is placed in a leg as a lifeline to provide fluid therapy and administer medications. Fluid therapy supports blood pressure and kidney function throughout your pet's procedure. A small square area will be shaved on the leg, and the IV catheter placed sterilely.

2. Anesthesia: Pre-surgical blood work and physical examination will enable us to minimize the risk of anesthesia to your pet. You will be called before the procedure if there are any abnormalities. We use the safest anesthetic agents available. You may also have been anesthetized with the same or similar agents.

3. Monitoring during the Procedure: To further minimize anesthetic risk, we monitor your pet's heart rate, respiratory rate, blood pressure, blood oxygenation, and anesthetic depth during the procedure.

4. Pain Management: We practice comprehensive pain management, using the safest and most appropriate agents for your pet's procedure. If the procedure warrants it, we will often dispense additional pain medications to administer at home.

Authorization and Risk Assessment:

I authorize anesthesia/surgery for my pet. The nature and risk of this procedure have been explained to me. I understand that some risks always exist with anesthesia and/ or surgery, and I have been encouraged to discuss any concerns I have about those risks with my Veterinarian before the procedure(s) is done. I authorize Cascade Animal Clinic to perform any additional diagnostics, treatment or procedure(s) deemed necessary, in case of any medical or surgical complication or otherwise unforeseen circumstances. While Cascade Animal Clinic provides the highest quality of anesthesia monitoring and surgical services, I understand these risks and understand the veterinarians and hospital staff will try to minimize such risks. I will not hold Cascade Animal Clinic, the veterinarians, or any of the staff liable for any complications that may arise.
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Date*

MonthDayYear
Date
CPR (Cardiopulmonary Resuscitation) Authorization:

While the following decision is a difficult one, our team wants to ensure we understand and act in accordance with your wishes regarding CPR, in case a crisis were to occur. Please read carefully and make a selection.

Anesthesia and surgery are not without intrinsic risk and rapid decisions may be required. While Cascade Animal Clinic closely monitors each patient, this does not fully eliminate the possibility of complications. In the event of an unforeseen circumstance or medical emergency, where immediate action is necessary to try to prevent the loss of life, and the attending Veterinarian determines there is not time to call the owner and discuss the situation before treatment:
I request:*

CPR be given: Including but not limited to; cardiac compressions (open or closed chest), endotracheal intubation (breathing tube), manual ventilation (breathing for the patient), and medications, in an effort to revive my pet.My pet does NOT receive CPR, DNR (do not resuscitate). In the event that my pet goes in to cardiac or respiratory arrest, I DO NOT want Cascade Animal Clinic to attempt to resuscitate my pet.
- I understand that CPR does not guarantee a favorable outcome and survival rates in veterinary medicine are typically less than 10%.
- I am aware that the cost of CPR can vary significantly, from $300 to exceeding $1000, and is not included in the treatment plan I was provided. I agree to pay this fee in addition to any fees already agreed upon by me.
- There is a very high chance of re-arrest and my pet will need immediate transfer to an emergency clinic or specialty center for continued monitoring and treatment.
- I understand that if my pet survives CPR, they may have permanent health issues, and/or brain damage.
Please Initial here to confirm your CPR selection:*
A deposit, minimally for the low-end amount of the treatment plan previously provided, is required at or before check-in time.
By entering my initials here, I confirm that I have received and reviewed a treatment plan, in the past 30 days, for the above listed procedure. I assume financial responsibility and will provide payment in full before, or at the time, my pet is discharged. *
Name of client or authorized agent who will be bringing the patient in:*
Phone Number ** Please make sure this is a number that you can be reached at while your pet is here for their procedure***

Area CodePhone Number
What is your preferred method of communication after surgery?*

Phone CallText Message
Does your pet have any food allergies?*

NoYes
Please explain: *
Is your pet on any chronic medications or supplements?*

NoYes
Please list all medications, including dose, and/or supplements:*
When did your pet last have any medications or supplements?*
Is your pet allergic to anything, including medications?*

NoYes
Please list any/ all allergies:*
Has your pet experienced any trauma or injuries in the past few months?*

NoYes
Please explain:*
Any dramatic weight loss or gain in the last few months?*

NoYes
If so, please explain:*
Has your pet been experiencing any of the following?*

VomitingDiarrheaCoughingSneezingWheezingNone of the above
If so, please explain:*
How long has this symptom been present?*
Has your pet experienced complications or issues with anesthesia in the past?*

NoYes
If so, please explain:*
If your pet is female when was the last time she was in heat? (If this does not apply please type n/a)*
If your pet is having a dental procedure would you like to be contacted before any extractions are performed?*

NoYesNot Applicable
Do you have any concerns or questions for the Doctor?*

NoYes
If so, please list/ explain:*
Other Services Requested: *Possible additional cost will apply if it was not already included on the treatment plan that was provided***

MicrochipNail Trim (complementary)Anal Glands ExpressedSedatives To Go HomeBiopsy of Mass RemovalComplete Parasite ScreenFecal OnlyFelv/Fiv TestNo other Services RequestedOther
It is very important that your pet does not lick or scratch their surgery site after their procedure. If you have a protective collar, or approved surgical suit at home, *it must be brought in with the patient at surgery check-in*. Otherwise, you will be billed for a protective collar, if we need to apply one, in order to protect your pet while they are here. Please confirm how you would like to proceed:*

I will bring a protective collar or surgery suit at check-in.Please apply a protective collar if needed.Please send a protective collar home, in case it is needed. (Not eligible for return).I decline a protective collar against medical advice.
By entering my initials here: I agree and understand that I will be financially responsible for the cost of treatment for any/all complications that may occur from my pet licking or scratching their surgery site. *
By entering my initials here: I agree that my pet will receive a rabies vaccine, with an additional cost, if I have not provided proof prior or if my pet is not current. *
I understand that my pet must not be fed after 8:00 PM the night before their procedure. It is ok to continue to give water. **Please type your initials***
I authorize Cascade Animal Clinic to share and/or publish my pet's name and photo on social media.*

YesNo
If you give authorization to share your pet(s) photo, please type your initials in the box. If not, type N/A.*
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