General Anesthesia Consent
Please read the information, then fill out applicable questions about your pet.
Today's Date
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Month
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Day
Year
Date Picker Icon
Name of Pet
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Anesthetic Procedure(s) to be Performed
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Primary Phone Number
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Area Code
Phone Number
Additional Phone Number (If I cannot be reached at the primary phone number)
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Area Code
Phone Number
Email
example@example.com
Which method of contact do you prefer today:
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Phone call
Text
Email
Is your pet experiencing any of the following:
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Coughing
Sneezing
Vomiting
Diarrhea
(none of the above) no coughing, sneezing, vomiting, or diarrhea.
Other
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.
Ear Cleaning
Nail Trim
Anal Gland Expression
Sanitary Clip
Microchip
Other
Does your pet have any food or drug allergies that you're aware of?
No
Yes
Other
Has your pet been prevented from eating (fasted) for the last 8-10 hours?
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Yes
No
Do you have any additional concerns or questions for the anesthesia team?
Please list the medications you give your pet, and the last time they were given. If none, please type 'none' in the first box.
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Name and Dose
Time Last Given
Date Last Given
Medication
Medication
Medication
Medication
I have been provided an estimate for the cost of services today and understand that payment for all services is due at the time of discharge from the hospital.
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Yes, I was given an estimate for services today that I agree to
No, I have not received an estimate
Critical Care Stabilization Authorization
In the event that your pet is deemed unstable on presentation to Strawbridge Animal Care or becomes unstable while in the care of your veterinarian, we ask you to define your wishes for stabilization treatments, care, and/or diagnostics. Your pet's medical care team will make every attempt to contact you prior to these procedures being performed, but in some instances it may be in your pet's best interest to have these procedures and/or diagnostics performed immediately. These procedures and/or diagnostics may include an urgent physical exam, an intravenous catheter, intravenous fluid therapy, oxygen support, blood work,and/or pain medications.
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I decline any immediate stabilization procedures and/or diagnostics. I understand that delayed emergency stabilization may cause my pet's prognosis to reduce to poor or guarded, depending on my pet's specific condition. I have the option to authorize these procedures and/or treatments at any point during discussions with my medical care team.
I elect and authorize stabilization procedures and/or diagnostics for my pet. I understand that depending on my pet's condition, these procedures may or may not improve my pet's prognosis; however they do improve the ability of my pet's medical care team to respond to changing conditions more rapidly and effectively. Critical care stabilization procedures and/or diagnostics can incur costs between $350-$450.
Signature
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Resuscitation Orders
If your pet goes into acute cardiorespiratory arrest, we ask you to define your wishes for administration of CPR and life saving measures. CPR is the resuscitation of an animal that has stopped breathing and /or whose heart has stopped beating. CPR is successful at returning normal heart, lung and brain function in, unfortunately, the minority of patients who have arrested. Animals that have survived cardiopulmonary arrest and have been successfully resuscitated (CPR) are critical and unstable. The likelihood of re-arrest is high following resuscitation and there is only about 15% short-term and
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I elect a DNR status for my pet, which means, "Do Not Resuscitate." This is a decision that CPR is NOT to be performed in the event that the pet stops breathing and/or heart beating. If you choose DNR, we will not attempt to revive your pet in an arrest situation and your pet will die naturally.
I elect for a CPR status for my pet, requiring the staff to perform CPR (resuscitation) on your pet if it suffers from respiratory and/or cardiac arrest. Please be informed that a pet may not respond to CPR, may respond initially and then suffer another arrest later, or may die despite CPR. On average, CPR can incur additional costs between $400-$500.
Signature
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I am the owner or the agent for the owner of the animal described and have the authority to execute this consent. I hereby consent and authorize the veterinarian(s) of Strawbridge Animal Care to perform the procedures listed . There is always risk associated with surgery and anesthesia. Some patients will be a higher anesthetic risk compared to others due to known or unknown physical or metabolic abnormalities. My pet’s anesthetic risk based on what we know about my pet has been determined by my veterinarian and explained to me. I understand that during the performance of the foregoing procedures or operations, unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure operation or different procedure or operation as those set forth. Therefore, I hereby consent and authorize the performance of such procedures and operations as are necessary and desirable in the exercise of the veterinarian's professional judgement. I understand that every effort will be made to contact me and advise me of any unforeseen change in the treatment plan. I have been advised of the services that Strawbridge Animal Care has the capabilities of performing as it pertains to the procedure(s) that I am authorizing. I have been advised that no staff is available on the hospital premises except during normal hospital operating hours. 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 will be available at the phone number(s) listed below at all times during the day of the procedure.
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Client/Owner Name
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First Name
Last Name
Submit
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