Atascocita Animal Hospital Anesthesia/Surgery/Treatment Consent Form

Atascocita Animal Hospital Anesthesia/Surgery/Treatment Consent Form

Please complete the form below for your pet to be admitted for anesthesia, surgery, and treatment.
Owner Name

First NameLast Name
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Pet Name

First NameLast Name
Requested Surgery or Procedure
Please list anyone who is authorized to pick up your pet:
Emergency Contact Name

First NameLast Name
Emergency Contact Cell Phone Number
Please enter a valid phone number.
Medical Information
Does your pet have any known medical issues or showing any signs of illness?

YesNo
Please explain medical history:
Does your pet take any medications?

YesNo
Medication name & directions:
Has your pet had any previous reactions to anesthesia?

YesNo
If yes, please describe the reactions:
Please state when your pet last had food/water:
Does your pet see another veterinarian?

YesNo
Please provide the clinic/hospital name and phone number so we can call to verify vaccination records:
Please list any behavioral concerns (biting, timidness, special handling):
Please list any information we should know about your pet, such as past surgeries:
Please list any belongings that will be left with your pet:
Policies & Procedures

Please review our policies and procedures, then consent at the bottom
Vaccinations & Flea Protection
I understand my pets must have a current physical exam and be up-to-date on the following vaccinations/testing: distemper, parvovirus, leptospirosis, rabies, bordetella (kennel cough) canine influenza (H3N2 and H3N8), and fecal (intestinal parasite exam). If my pet has been vaccinated at another hospital or clinic, I understand the hospital MUST receive a copy of my pet’s vaccine records. Should I opt NOT to receive reminders from the hospital, I understand that I am responsible for keeping up with these requirements, as some veterinary clinics require boosters and/or fecal analyses at different times. The hospital follows the AAHA guidelines and requires that all dogs in group housing environments be vaccinated against kennel cough (bordetella) annually as they are considered “high risk.”

Authorization & Release of Liability
I verify that I am the owner (or Authorized agent for the owner) of the above named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian.

I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. For pets 7 years of age or older, the veterinarian may deem additional treatment and pre-surgical procedures necessary for the procedure. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgement. I accept responsibility for any result in additional charges.

I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).
I have read and agree to the policies and procedures for anesthesia, surgery, and/or treatment and have verified all information listed above.

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Atascocita Animal Hospital Anesthesia/Surgery/Treatment Consent Form

Medical Information

Policies & Procedures