Veterinary Vision Center - Sedation Anesthesia Consent

1
Client Contact Information on Procedure Day* This field is required.We need to know how to contact you.
Name
Land Line Number
Email
Cell Phone
Cell Phone - Call
Cell Phone - Text
Land Line Phone
Email
Which contact method should we use to contact you
2
Name
3
Your Pet's Information* This field is required.
Pet's Name
Male
Male Neutered
Female
Female Neutered
Sex
Canine
Feline
Rabbit
Ferret
Other
Species
Breed
Color
Age
4
Night CareIf your pet is staying the night at UVH. What is your preferred method of contact during evening hours so the night nurse can update you. **Please bring ALL of your pet's medications.
TEXT
CALL
EMAIL
5
Night Care Phone Number* This field is required.If your pet is staying the night at VVC, what is the best number for us to call with an evening update before 9:00 PM.
Area Code
Phone Number
6
Does your pet take medications or supplements routinely?
YESNO
7
What and When??? We need to know what medications you give your pet in the morning vs which ones in the evening.
Huge
Large
Normal
Small
Ok
Ok
8
Do you need any medications refilled?Please list what you need refilled and the quantity you want refilled.
Huge
Large
Normal
Small
Ok
Ok
9
Planned Procedure Date* This field is required.
Date
Year
Month
Day
10
What procedure(s) will be performed.* This field is required.
11
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.

*Heartworm testing is not considered preanesthetic lab work.

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 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.

VVC 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.
12
Select One - Preanesthetic Laboratory Consent* This field is required.
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. **Heartworm testing is not pre-anesthetic bloodwork.
13
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 University 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 Veterinary Vision Center, 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.
14
Payment Policy - 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?* This field is required.
Cash
Credit Card
CareCredit
15
If it becomes necessary during your pet's visit, do you want us to administer CPR?* This field is required.
YES - 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.
NO - DNR - In the event that my pet's heart and or breathing should stop requiring cardiopulmonary resuscitation (CPR), I decline any and all emergency intervention. Do Not Resuscitate (DNR).
16
Owner's signature* This field is required.
Clear
17
Signature Date* This field is required.
Date
Year
Month
Day
3
1
2
3
4
5
6
7
8
9
10
11
12
Hour
40
00
10
20
30
40
50
Minutes
AM
AM
PM
18
Owners acceptance* This field is required.I have read and fully understand the sedation, anesthesia, and/or surgery consent form.
Should be Empty:

Authorization and Risk Assessment