Anesthesia Consent Form

Client Name

First NameLast Name

Best Phone Number to Reach Me Today

Area CodePhone Number

Date of Appointment

Date

Pet Name

Procedure Being Performed Today

I am aware that my pet is not supposed to have any food after 8:00pm the night before surgery. I am aware that my pet can continue to be offered water until I drop off the morning of the day of surgery.

(YES or NO)

When was the last time your pet ate?

Is your pet currently taking any medications? If so, please list what medications and the last time they were given.

I understand that if any external parasites are found on my pet, proper treatment will be given while in the hospital and charged to me.

Additional Surgical Services (Please realize that the prices shown below are over and above the price of the surgery):

If having a dental cleaning, I approve any necessary dental extractions (Cost Varies)

Other Additional Services (Please realize that the prices shown below are over and above the price of the surgery):

Regular Nail Trim ($15)Show Nail Trim ($15)Anal Gland Expression ($23)Microchip ($35)

I have received and approved a detailed estimate for the procedure being performed today. *If not, we will send you an estimate for approval BEFORE doing any procedure. The estimate must be signed and approved by you before we will proceed with the scheduled procedure.

Please Read Carefully and sign below

Like you, our greatest concern is the well-being of your pet. Your pet is scheduled for an anesthetic procedure. All anesthesia and surgery involve some potential risks and complications, including death. Before putting your pet under anesthesia, we will perform a full physical examination. We also recommend that a pre-anesthetic blood profile be performed to maximize patient safety and alert the doctor to the presence of dehydration, anemia, infection, diabetes, and kidney or liver disease, which would complicate the procedure. These conditions may not be detected without a preanesthetic profile. These tests are similar to those your own physician would run if you were to undergo anesthesia. In addition, the results of these tests may detect health changes earlier and allow more accurate diagnosis and treatments. If abnormalities are found, we will contact you at the number above.

Other procedures can decrease the risk to your pet if problems arise. One of these procedures would be the placement of an intravenous catheter which can be used to administer fluids and medication in case of complications. IV fluid therapy will help to keep blood pressure up and ensure perfusion (blood flow) of all organs. It also helps to hydrate the animal as they are not allowed to drink much the day of the procedure. Dehydration can increase recovery time and contribute to nausea and fatigue. If unexpected problems arise and you are unable to be reached by phone, the doctors have the right to make medical decisions for your pet.

Signature