The Urban Vet - Anesthesia Procedure Consent Form

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Client Information* This field is required.
Client Name
Phone
Email
Pet's name
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Contact Phone Number for day of procedure (emergency contact#)* This field is required.
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Anesthesia:
I authorize the use of general anesthesia for my pet. All patients undergo a full physical exam, have pre-anesthetic bloodwork performed, and have continuous cardiopulmonary monitoring while under anesthesia. I understand that although great care is taken to ensure the safety of my pet, unexpected complications, including death, can occur with general anesthesia. I understand that all complications will be addressed immediately, and all necessary procedures performed. I understand the hospital support personnel will be used as deemed necessary by the veterinarians.
Please Initial *
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Surgical Procedure to be performed: *
I have had the opportunity to discuss, understand, and ask questions about the procedure with the veterinarian and support personnel. I authorize the use of appropriate pain relief medication as needed before and after the procedure. I have been informed that there are risks associated with the use of any medication. I understand that the procedure will require the staff to shave certain areas of my pet.
Please Initial *
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Microchip Implantation: A microchip aids in the identification and recovery of a lost pet. This may be implanted while your pet is under anesthesia. Would you like to add this simple procedure to your pet’s plan?
Yes
No
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Dental Surgical Consent: PLEASE CHECK ONE BELOW: * This field is required.The full extent of dental disease cannot be determined until a thorough dental exam and dental x-rays are performed under anesthesia. I understand that dental pathology requiring surgical intervention, including dental extractions, periodontal treatment and gum surgery, may become apparent during this examination. If additional procedures are recommended:
I prefer to proceed with dental surgical procedures as deemed medically necessary by Dr. Cagle.
I prefer to be called prior to any additional procedures, other than emergencies, at the above number. However, if I cannot be reached, I authorize unforeseen non-emergency procedures.
I prefer to be called prior to any additional procedures, other than emergencies, at the above number. However, if I cannot be reached, I do NOT authorize unforeseen non-emergency procedures. I understand that an additional anesthetic procedure may need to be performed to accomplish recommended procedures.
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Please Check Below* This field is required.
My pet has been fasted since 12:00am the night prior to surgery.
My pet has no history of adverse drug reactions/allergic reactions to medications.
In the event of a life-threatening emergency I would like the veterinarian and staff to perform CPR.
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Please list any current medications or supplements your pet is currently taking
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I am the owner or authorized agent of this animal. I authorize the veterinarians and staff of The Urban Vet to perform the procedure(s) needed to ensure my pets health. I understand the procedure and possible risk that my pet will undergo. Furthermore, in case of an emergency, I consent to any necessary procedure not set forth in this form. I understand that all costs associated with this procedure are due upon discharge of the patient.
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Month
Day
Year
Should be Empty: