Anesthesia Consent Form

Procedure date *

Month Day Year

Name of Pet *

Like you, our greatest concern is the well being of your pet. Prior to anesthetizing your pet, our doctors take the following measures for every surgical patient.

Surgical Requirements:

A pre surgical exam is performed on all patients before anesthesia.

Anesthetic monitoring is performed by our trained staff. Heart rate, body temperature, pulse oximetry and respiratory rate are some of the specific parameters we monitor. These vital signs are continuously assessed to help create the safest anesthetic environment possible.

The control of pain is very important aspect of the surgical procedure. Our goal is to minimize the inherent discomfort associated with all surgical procedures. A pain free animal requires a lower level of anesthesia, increasing the safety for your pet and helping to ensure a smooth and speedy recovery. Our pain management protocol is required in all surgical patients. The medications used and length of treatment will vary based upon the procedure performed and the degree of pain involved. If needed, further out-patient medications will be prescribed for your pet to continue at home.

Surgical Options- please select choice below: Some optional services listed may be required based on the surgical procedure and the Dr. recommendations.

IV Fluid Therapy: is important to the maintenance of homeostatis during anesthesia and provides venous access for supportive therapy, for maintenance of anesthesia, and for cardiopulmonary resuscitation. There will be a small shaved portion on your pet's leg.

Blood testing (Complete Blood Count (CBC), Chemistry Panel, Electrolytes): Blood testing is advised on all pets prior to anesthesia. Many conditions, including disorders of the liver or kidneys, low grade infections, or electrolyte abnormalities can only be detected through blood testing and examinations, especially before your pet shows clinical signs of illness. Detection of these conditions prior to surgery will decrease the risks associated with anesthesia. In many cases, such as geriatic or sick patients, the doctor may require blood testing prior to anesthesia. Our in-house laboratory is equipped with the latest technology to perform blood screening tests. If a problem is detected during the physical exam or on the blood work, a doctor will contact you to discuss any recommended course of action prior to surgery. Surgery will be postponed if it is deemed to be in the best interest of your pet.

Microchip implantation (Datatmars microchip): Microchipping is available and can easily be placed into your pet by injection. The chip is the size of a grain of rice and will permanently identify your pet in case they are ever lost. A handheld scanner identifies the number which, after registration, is permanently traceable to the owner. We will also register your pet with Datamars, a service which is included in the price of the implantation.

Addition Anesthetic Monitoring: Is offered by our trained staff, using the best technology available. In addition to the above essential monitoring we also offered to monitor blood pressure, electrocardiogram, core body temperature, and end tidal CO2. These vital signs are continuously assessed to help create the safest anesthetic environment possible.

Laser Surgery: A laser scalpel cauterizes as it cuts, which results in little to no blood loss to the incision site. Laser surgery has been found to reduce pain and swelling after a procedure.

Therapy Laser: We also offer our therapy laser as a post-op service to help provid immediate pain and swelling relief at the surgical site. This quick, pain-free procedure desensitizes nerve endings and promotes healing of the tissues involved. Therapy is not advised around the eyes or in situations with suspected cancer.

Surgical options that are advised while your pet is here for surgery (please check box to authorize or decline services) additional fees apply.

I authorize IV Catheter & Fluid Therapy to be performed on my pet during their anesthesia event.

Yes, I authorize. No, I decline.

I authorize pre-surgical blood-work to be run on my pet prior to anesthesia to assess organ health. I understand that this option may be required based on my pet's age or health status and will therefore be discussed with me during my pet's stay. *

Yes, I authorize. No, I decline.

I authorize the use of additional anthestic monitoring to be performed on my pet during anethesia.

Yes, I authorize No, I decline

I authorize permanent identification in the form of a Datamars Microchip to be implanted in my pet while they are here for anesthesia. If your pet already has a microchip, we will not implanting a second one. *

Yes, I authorize. No, I decline.

I authorize the use of laser scalpel for my pet's surgical procedure.

Yes, I authorize No, I decline

I authorize post-operative laser therapy to be performed on my pet during their anesthesia recovery. If yes is selected, it will still be performed at the doctor's discretion and may not be performed. *

Yes, I authorize. No, I decline.

I hereby consent and authorize the following procedure(s) be performed

Canine Spay Canine Neuter Feline Spay Feline Neuter Feline Declaw Sedation

Is your pet in heat? The Doctors at NOAH recommend waiting until your pet has completely finished their heat cycle before the spay procedure.

Yes No

When was your pet's last heat cycle?

Date

Primary Phone Number *

Area Code Phone Number

Select if you prefer a text message

Yes, please text the above number

Additional Phone Number (If I cannot be reached at the primary phone number)

Area Code Phone Number

Email

example@example.com

I would like these additional procedures to be performed during my pet's visit. I understand these procedures may incur charges beyond what I was estimated for the original procedure.

Vaccinations; Rabies is required Clean ears Anal Gland Expression

Does your pet have a history of seizures or other neurologic disorder? *

Yes. No.

Do you have any additional concerns or questions for the anesthesia team?

Please list the medications you give your pet, the last time they were given and if you need a refill.

	Name and Dose	Frequency Given	Time Last Given	Date Last Given	Refill Needed
Medication
Medication
Medication
Medication

Name *

First Name Last Name

I attest that I understand the nature of the procedure(s) that has been explained to me and no guarantee has been made as to the results or cure. I understand that there are inherent risks associated with anesthesia and/or surgical procedures. I will not hold North Ogden Animal Hospital, its doctors, or staff liable for any complications. I will be available at the phone number(s) listed at all times during the day of the procedure. If the doctors and staff at NOAH cannot reach me by phone, I agree to allow any treatment deemed necessary for the health of my pet. *

Clear

I understand that payment for this procedure and any services at North Ogden Animal Hospital is required the day they are performed. I understand that an estimate is a living document and is subject to be changed throughout the day, based on new information gathered after anesthesia is achieved. I understand that the anesthesia team will be in contact with me during the day as new conditions arise. *

I have received an estimate for the procedure(s) and understand the potential charges. I have not received an estimate for the procedure(s), and would like one to be emailed to me. I have listed my current email address in this form.