Veterinary Vision Center - Sedation Anesthesia Consent (Old 2)

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Pet's Name
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Weight(kg)
Species
Breed
Sex
Colour
Est. DOB
Age
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First Name
Last Name
Phone
Email
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Preanesthetic Laboratory Consent

You or I would have current lab work performed by our doctors before any major sedative or anesthetic procedure, no questions asked. It would be considered malpractice if they did not! Would you feel comfortable undergoing sedation or anesthesia without your risks evaluated?

General anesthesia and sedation drugs can all cause potentially dangerous changes:
1. Lower blood pressure
2. Heart rate and heart rhythm changes
3. Depression of respirations, low blood oxygen and high carbon dioxide levels

It is well documented that dogs and cats above the age of 7 years old, have increased risks of :
1. Kidney disease
2. Liver disease
3. Heart & Lung disease

Any preexisting kidney, liver, or heart disease can dramatically increase sedative/anesthetic drug side effect and increase the possibility and severity of anesthetic/sedative complication, including cardiac arrest.

At VVC, our general anesthetic and sedative guidelines are as follows:

1. We will not perform major sedation or anesthesia on your pet if they are over 7 years old without current (within 3-4 weeks), age-appropriate bloodwork.
2. We strongly recommend that pets requiring frequent sedative grooming, bathing, minor medical procedures under 7 years old have age appropriate lab work performed once every 6 months minimally.
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Select One
I consent to the standard VVC sedative and treatment guidelines as stated above and approve lab work being performed.
Pre-anesthetic bloodwork has already been performed.
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Owner's signature
Clear
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Date
Date
Year
Month
Day
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Veterinary Vision Center Monitoring

• We further minimize anesthetic risk by monitoring heart rate and rhythm, respiration rate and quality, oxygenation, blood pressure, ECG readings, temperature, and depth of anesthesia during the procedure.

• For all general anesthetic procedures, an intravenous catheter is placed to provide us with an easy route to administer medications and fluids (which support kidney function and blood pressure) during the procedure.

• We will proactively manage pain associated with any procedure with appropriate pain management medications. As with any drug, side effects may be associated with administration.
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Planned Procedure Date
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Name
Phone Number
Email
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Night CareIf your pet is staying the night at VVC. What is your preferred method of contact during night hours.
TEXT
CALL
EMAIL
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If it becomes necessary during your pet's visit, do you want us to administer CPR?
Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, emergency drugs or other heroic interventions, I authorize that the doctors at this hospital provide such medical care.
In the event that my pet's heart and or breathing should stop requiring cardiopulmonary resuscitation (CPR), I decline any and allemergency intervention. Do Not Resuscitate (DNR).
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YES - I was given a written/verbal estimate and understand that payment is expected in full at time of services rendered. I understand that VVC reserves the right to ask for a down payment before starting the procedure. What form of payment will you be using today?
Cash
Credit Card
CareCredit
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Authorization and Risk Assessment

I hereby certify that I am the owner of the above-named animal or I am responsible for it and have the authority to execute this consent. I authorize sedation/anesthesia/surgery for my pet. The nature and risks of this procedure have been explained to me. I understand that some risks always exist with sedation / anesthesia and /or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any questions have been answered to my satisfaction.

I authorize Veterinary Vision Center to perform any additional diagnostic, treatment or surgical procedure(s) deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. While Center provides the highest quality of anesthesia monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures.I fully understand these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I will not hold VVC, the veterinarians, or any staff member liable for any complications that may arise. I assume full financial responsibility for all services rendered.

I have read and fully understand the sedation, anesthesia, and/or surgery consent form.
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Owner's signature
Clear
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Date
Date
Year
Month
Day
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Admitting Team Members' initials
Clear
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Date
Date
Year
Month
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Should be Empty:

Veterinary Vision Center Monitoring

Authorization and Risk Assessment