Anesthesia Information and Consent

Name of Pet*

Your First Name*

Your Last Name*

Primary Phone Number you may be reached on the the day of the procedure.*

Area CodePhone Number

Today's Date*

MonthDayYear

Date of Procedure *

Date

Anesthetic Procedure(s) to be Performed*

When did your pet last eat? (Pets should not eat after 8 PM the night before an anesthetic procedure)*

Does your pet have any known allergies?*

In the past 48 hours, please select if your pet has experienced any of the following:*

All pets presented for surgery must have current Rabies vaccinations. A copy of a current Rabies Certificate or confirmation by telephone from the veterinarian administering the vaccination is required. A Rabies Tag is not acceptable. Cats must have a current Distemper Vaccine. Dogs must also have current Distemper, Kennel Cough and Influenza Vaccines. (Initial)*

Any animal found to be harboring external or internal parasites will be treated at the owner’s expense. (Initial)*

Like you, our greatest concern is the well being of your pet. Prior to anesthetizing your pet, our doctors will perform a complete physical examination. In addition, the following measures are taken for every surgical patient.

Surgical Requirements:

An intravenous (IV) catheter is required for all anesthetized patients. Catheter placement enables us to administer IV fluids during the surgical procedure, helping prevent low blood pressure and dehydration in your pet. It also allows for the administration of any pain medications, antibiotics, or emergency drugs if necessary. Pets are often premeditated prior to IV catheterization to reduce stress and the leg shaved at the placement site to help maintain sterility.

Anesthetic monitoring is performed by our highly trained and/or licensed staff, using the best technology available. Heart rate, blood pressure, electrocardiogram, core body temperature, pulse oximetry, and respiratory rate are some of the specific parameters we monitor. These vital signs are continuously assessed to help create the safest anesthetic environment possible.

Pre-anesthetic EKG can help us identify drug effects on the heart, so is especially important for preanesthetic testing. By performing an EKG on your pet prior to anesthesia, we can evaluate their normal cardiac function, and then monitor effects of the anesthetic drugs on their heart rate and rhythm.

Pain Management The control of pain is a very important aspect of the surgical procedure. Our goal is to minimize the inherent discomfort associated with all surgical procedures. A pain free animal requires a lower level of anesthesia, increasing the safety for your pet and helping to ensure a smooth and speedy recovery. Our pain management protocol is required in all surgical patients. The medications used and length of treatment will vary based upon the procedure performed and the degree of pain involved. If needed, further out-patient medications will be prescribed for your pet to continue at home.

Blood testing-Complete Blood Count (CBC), Chemistry Panel: Blood testing is advised on all pets prior to anesthesia. Many conditions, including disorders of the liver or kidneys, low grade infections or anemia can only be detected through blood testing and examination, especially before your pet shows clinical signs of illness. Detection of these conditions prior to surgery will decrease the risks associated with anesthesia. Cape Fear Animal Hospital requires blood testing prior to anesthesia. Our in-house laboratory is equipped with the latest technology to perform blood screening tests. If a problem is detected during the physical exam or on the blood work, a doctor will contact you to discuss any recommended course of action prior to surgery. Surgery will be postponed if it is deemed to be in the best interest of your pet.

Therapy Laser: We also offer our therapy laser as a post-op service to help provide immediate pain and swelling relief at the surgical site. This quick, pain-free procedure desensitizes nerve endings and promotes faster healing of the tissues involved. This modality is used at the doctor’s discretion, as laser therapy is not advised around the eyes or in situations with suspected cancer.

Additional Phone Number (If I cannot be reached at the primary phone number)

Area CodePhone Number

Email

example@example.com

The following procedures may be easily performed while your pet is sedated: (please check box to authorize or decline).

I authorize permanent identification in the form of a Microchip to be implanted in my pet while they are here for anesthesia. If your pet already has a microchip, we will not be implanting a second one. ($51.50)*

Yes, I authorize.No, I decline.

I would like these additional procedures to be performed during my pet's visit. I understand these procedures may incur charges beyond what I was estimated for the original procedure.

Nail Trim (Complimentary)Nail Trim with Dremmel ($31.50 or $20.00 with a Paw Plan)Anal Gland Expression ($36.75)Other

Does your pet have a history of seizures or other neurologic disorder?*

Yes.No.

Do you have any additional concerns or questions for the veterinarian or anesthesia team?

Please list the medications you give your pet, and the last time they were given.*

	Name and Dose	Frequency Given	Time Last Given	Date Last Given
Medication
Medication
Medication
Medication

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedures today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:*

Please proceed with life-saving measures. I will accept responsibility for all costs incurred regardless of my pet's survival.Please do not proceed with life-saving measures. I accept responsibility for all costs incurred regardless of my pet's survival.

I understand that payment for this procedure and any services at Cape Fear Animal Hospital is required the day they are performed. I understand that an estimate is a living document and is subject to be changed throughout the day, based on new information gathered after anesthesia is achieved (such as dental radiographs, abdominal exploratory, etc). I understand that the anesthesia team will be in contact with me during the day as new conditions arise.*

I have received an estimate for the procedure(s) within the last 60 days, and understand the potential charges.I have not received an estimate for the procedure(s), and would like one to be emailed to me. I have listed my current email address in this form.I have not received an estimate, and I do not want one. I understand that payment for today will be required at pick-up.

By signing below with my finger or mouse, I attest that I understand the procedure to be performed on my pet and have no further questions at this time. I acknowledge there may be concealed health risks to my pet and release Cape Fear Animal Hospital and staff from any unforeseen complications arising from anesthesia/surgery. I will be available at the phone number(s) listed below at all times during the day of the procedure. If the doctors and staff at CFAH cannot reach me by phone, I agree to allow any treatment deemed necessary for the health of my pet. *