Sedation/Anesthesia Consent Form

Thurman Veterinary Center
Anesthesia/ Sedation Risk Consent Form
Owner Name: *
Patient's Name: *
Phone number(s) where you can be reached today: *
Reason for visit today: *
HAS YOUR PET HAD ANY FOOD OR WATER PAST MIDNIGHT LAST NIGHT? Please inform us if your pet has had any food or water after midnight, vomiting during and after surgery is very common and if they aspirate food/water they can have severe anesthesia complications which can lead to death. *

YES NO
PRE-ANESTHETIC BLOODWORK: Anesthetic episodes carry an inherent risk. Undoubtedly the importance of the procedure outweighs the potential for complications. Pre-anesthetic bloodwork will help minimize the risks during anesthesia and surgery. By testing blood chemistries and hematology values, we can better evaluate the status of your pet's major organ systems. (REQUIRED for pets over 7 years of age).
Would you like your pet to have pre-anesthetic blood work? *

Yes, I consent to pre-anesthetic blood work ($75) No, I decline pre-anesthetic blood work and have been informed of the risks.
ADDITIONAL SERVICES WHILE UNDER SEDATION:
Would you like your pets nails to be trimmed while sedated ($15-$30)

Yes No
Would you like your pet to have their anal glands expressed while sedated?

Yes No
CONSENT FOR TREATMENT AND ANESTHESIA
I understand that anesthesia/sedation comes with inherent risks and that complications and even death are possible. I understand that during the performance of the exam/procedures for the above situation(s), unforeseen conditions may be revealed that necessitate and extension of the foregoing procedures, or even procedures necessary and desirable in the exercise of the veterinarian's professional judgment. I understand that some risks exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the veterinarian before beginning the procedure. Should unexpected life-saving emergency care be required and the veterinarian or staff member is unable to reach me, the hospital staff has my permission to provide such treatment, and I agree to pay all fees incurred. I have been advised of the nature of the services and procedures, as well as the risks involved, and I also realize that results cannot be guaranteed. I additionally authorize the use of appropriate anesthetics, and the administration of other medications, and understand that hospital staff will be utilized as deemed necessary by the veterinarian.

**If your animal is displaying signs of having fleas/ ticks/ worms and is found to be carrying them, we will AUTOMATICALLY treat the animal at a cost to the client. Thank you for understanding.

I am the owner/Agent, of the above described animal, and have the authority to execute this consent and authorization.
(Signature of Owner/Agent) *

Clear
Date *

Month Day Year
Date
Should be Empty:

Thurman Veterinary Center

ADDITIONAL SERVICES WHILE UNDER SEDATION:

CONSENT FOR TREATMENT AND ANESTHESIA