Surgery Consent Form

Owner's Name:*

Pet(s) Name:*

Procedure:*

Phone number where you can be reached (in case of emergency)*

Alternate Contact:

Alternate Contact Phone:

Please read the following carefully

Cole Veterinary Clinic’s mission is to provide quality, personalized care for your pet. With regards to anesthetic and surgical procedures, this means we treat every patient individually, and will make every possible effort to minimize risk during any anesthetic procedure. However, risk is still inherent with anesthesia, even in young, healthy patients; although rare, complications and death can sometime occur.

One way to minimize anesthetic risk is by doing a blood panel to assess proper internal organ function (effectively process and eliminate anesthesia from the body), and blood cell counts (anemia, infection, clotting assessment). Having this information can help the Doctor to make the most informed decision regarding anesthetic options and timing of anesthesia. In the event there is a severe abnormality, we will call you prior to proceeding with anesthesia. By choosing one of the following options, I am providing informed consent for today's anesthetic procedure.

Pre-Op Panel 1: A basic blood screen for healthy patients under 7 years of age.Pre-Op Panel 2: A more comprehensive panel for older pets or with a known medical problem.I DECLINE pre-anesthetic testing.

When was the last time your pet ate (including any treats)?*

Please list any medications or supplements your pet is taking, or has taken in the past two weeks, and the last time they received the medication:*

YesNo

In the rare event of an emergency complication in which phone authorization cannot be obtained, either through non answer or immediate time constraints, I authorize Dr. Cole and his staff to provide the necessary critical care and resuscitation efforts. I understand that this may incur additional expenses.

I understand that my patient will receive resuscitative efforts (Please Initial):*

Owner/Authorized Representative

Date:*

Date

Owner/Authorized Representative:*