River Road - Anesthesia Consent Form

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Your Info: * This field is required.

Pet's Name

Your Full Name

2

Your Contact Details

Best Contact Number

Emergency Contact Number

Email

What is the best way to reach you?

Any availability limitations?

3

Procedure Details

Procedure

Performed by

Surgery Date

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Your pet must arrive fasted. The night before the procedure, please pull away food and water. Give any routine medications as normal unless otherwise instructed by the doctor.* This field is required.

I understand and agree.

5

Your pet must be dropped off between 7:00AM and 7:30AM. When you arrive, call from your car and a technician will come out to your vehicle.* This field is required.

I understand and agree.

6

In order to provide the best care available for your pet, we strongly recommend pre-anesthetic blood work to help identify any underlying metabolic/systemic abnormalities. All animals will benefit from the blood work, but we strongly urge all large breed dogs over 5 years of age and all small breed dogs and all cats over 7 years of age have complete blood work performed prior to any anesthetic procedure.

This panel costs $69 if done at least 24 hours prior to procedure, and $99 if done the day of procedure.

7

Would you like to have pre-anesthetic bloodwork performed on your pet?* This field is required.

Yes, I would like to identify any pre-existing health problems that might adversely affect the anesthesia.

No, I do not wish to have any blood work performed on my pet.

I have had blood work done on my pet recently.

I have questions/would like to discuss further at drop-off.

8

Would you like your pet to receive a microchip while sedated?

Yes ($63.04)

No

9

Is your pet currently taking any medications?* This field is required.

Yes

No

10

If yes, please provide to following: Drug name, strength, and amount/frequency given.***Note: Please give all morning medications before drop-off unless otherwise instructed by doctor.

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In the event that a life-threatening emergency were to happen while your pet is sedated and we are unable to reach you, do we have your permission to provide life-saving care? We will do our best to contact you prior to going over $500 if possible. * This field is required.

Yes

No

12

DENTAL PROCEDURES: If your pet is having a dental procedure done today, we may need to contact you once your animal is put under anesthesia. In the event that your pet needs extractions, please answer the following:**Note: If you cannot be contacted, we WILL proceed with all extractions thought to be necessary at the veterinarian's discretion**

I would like to be contacted before any extractions are performed.

Extractions can be performed without contacting me (can be up to an additional $500 of services)

My pet is not getting dental work done.

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GROWTH REMOVALS: In some cases where tissue is removed, examination of the tissue by a pathologist may be recommended by the doctor for further testing.

Yes, please submit tissue for histopathology. (~$200.00)

No, I do not desire histopathology.

My pet is not getting a growth removal.

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I, the undersigned owner or agent of the aforementioned pet, certify that I am at least eighteen years of age and authorize the veterinarian(s) at River Road Veterinary Hospital to perform the stated procedures. I understand that some risks always exist with anesthesia and/or surgery, and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian(s) before the procedures are initiated. While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I understand that any prices quoted for such procedures are for non-complicated operations and that any unforeseen complications may result in further cost. I assume financial responsibility for all charges incurred to patient, and I consent to the release of medical information for the said animal.

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Signature* This field is required.

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