Sedation & Anesthesia Consent

Sedation & Anesthesia Consent
Pet's Name*

First NameLast Name
Primary Contact*

First NameLast Name
Primary Contact Phone Number*

Area CodePhone Number
Text Messaging OK?*
If your pet is having a dental procedure performed, would you like us to send before and after photos by text message?
Alternate Contact*

First NameLast Name
Alternate Contact Phone Number*

Area CodePhone Number
Text Messaging OK?*
Email Address*
example@example.com
Should you choose, the following services are available to your pet while under sedation or anesthesia for an additional cost:

Microchipping + RegistrationComplete Annual Vaccines + Testing PackageRabies Vaccine (dog or cat)Distemper/Parvo Vaccine (dog only)Bordetella Vaccine (kennel cough)Canine Influenza Vaccine (dog flu)FVRCP Vaccine (feline distemper)Feline Leukemia VaccineHeartworm TestProheart 6 month Heartworm ShotIntestinal Parasite (Worm) ScreeningNail TrimExpress anal glandsEar cleaningRefill Heartworm/ flea prevention
Please initial to agree to the additional services checked above.
Estimates

Following the receipt of this form, we will prepare an estimate for you outlining the predicted cost of services. Please be prepared to sign this at the hospital front desk at check in OR call to arrange completing this by phone BEFORE dropping off you pet. Estimates not only outline the cost, they also confirm all the services you are approving for your pet.
Please initial for acknowledgement*
Anesthesia & Risks

By completing and signing this document, I understand that during the performance of the foregoing procedure or surgery, unforeseen conditions may be revealed that necessitate an extension of the procedure or surgery, or of different procedures than those set forth above. Therefore, I hereby consent to, and authorize, the performance procedures or surgeries as deemed necessary by the veterinarian. I have been advised as to the nature of the procedure(s) or surgery and the risks involved. I understand that results cannot be guaranteed. I understand that Lafayette Veterinary Care Center takes every precaution to reduce the risks involved with sedation, anesthesia and surgery for all pets. This includes repeating a physical examination, pre-anesthetic blood testing to evaluate your pet’s internal organ function and immune system, weighing a precisely calculating medications, placing an intravenous catheter and initiating fluid therapy, and monitoring them under anesthesia each manually (a person) and with anesthetic equipment. Although these precautions are known to significantly reduce the risks of anesthesia, some risks do still exist. Should any significant findings be found during your pet’s pre-anesthetic exam or blood-testing, we will call you immediately. Please remain available by phone and list a primary and secondary method of contact below.
Please initial for acknowledgement*
Please choose one of the following
I wish the staff to perform CPR (Resuscitation) on my pet if my pet suffers respiratory or cardiac arrest. I understand that my pet may not respond to CPR or may respond initially and then suffer another arrest later. I understand that my pet may die despite CPR. I understand that if my pet survives because of CPR,he/she may have brain damage. The estimate for initial CPR is $100 to $300. The estimate for the first 24 to 48 hours of veterinary care after CPR depends partially on pre-existing injury or illness
I DO NOT want CPR performed on my pet. I elect to have DNR (Do Not Resuscitate) orders placed on my pet’s record OR I elect that the veterinary staff stop the initial attempts at CPR that may have been started while I was being informed of the condition of my pet and my options.
Home Care & Pain Control
Because we care about your animal’s comfort and strongly believe that pain relief is important, additional pain medications will be provided, as needed, to control the level of your animal’s discomfort both after surgery and during their recovery at home. Would you prefer to take home (choose one):*

Liquid MedicationTablet MedicationsWhichever the Veterinarian Chooses
Following surgery, many pets instinctively lick and groom their incision sites. To prevent this and allow optimal healing, we recommend an E-Collar (cone collar) to prevent this.*

Yes, please send an e-collar home (recommended)Against LVCC's recommendation, I decline purchasing an e-collar post-operatively and assume financial responsibility for any medical treatments needed to address problems that may arise from doing so.
In the event I cannot be reached during my pet's dental, I elect to proceed as follows:*

My pet is not having dental work performed.I authorize the Doctor to perform any necessary procedures/extractions for my pet's best health at an additional cost of up to $100.I authorize the Doctor to perform any necessary procedures/extractions for my pet's best health at an additional cost of up to $200.I authorize the Doctor to perform any necessary procedures/extractions for my pet's best health at an additional cost of up to $300.I authorize the Doctor to perform any necessary procedures/extractions for my pet's best health at an additional cost of up to $400.I authorize the Doctor to perform any necessary procedures/extractions for my pet's best health at an additional cost of up to $500.I authorize the Doctor to perform any necessary procedures/extractions for my pet's best health at an additional cost of up to $1,000.If I cannot be reached within a 5-10 minute period, please do not perform any procedures/extractions not included in my original treatment plan. **An additional anesthetic procedure would be needed to perform these services at a later date.
Is there any other pertinent information you’d like to share with us? i.e. illnesses or symptoms your pet is displaying, other services you are interested in receiving?
DateTime
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Sedation & Anesthesia Consent

Please choose one of the following