Patient Admission/Consent Form

General Admission and Consent Form

Please answer/review and complete the CPR and DNR sections
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pet Name
Has your pet had any food or water since midnight last night?
Please select if your pet has had any of these symptoms
Do you want your pet microchipped?
Are you aware of any allergies your pet may have?
If yes please list:
Is your pet currently on any medications?
If yes please list them and when they were given:
Has your pet ever had an adverse reaction to any medication?
If yes please explain:
Authorization for procedure: I, the undersigned, being the owner or authorized agent of the animal described above, hereby authorize the veterinarians at Centralia Animal Hospital to perform the following procedure:
Anesthesia and Surgical Risk

I understand that all anesthesia and surgery involve some risk of complications, including infection, reaction to medications, or, in rare cases, death. I acknowledge that no guarantee has been made as to the results or cure.

Pre-Anesthetic Blood Screening
To minimize risks, we recommend a blood profile to check internal organ function (liver/kidneys) and blood counts prior to anesthesia.

Pain Management & Home Care
All surgical patients receive injectable pain medication. We will also dispense oral pain medication for you to administer at home for the next 3–5 days.
CPR/DNR Preference
Signature
Brachycephalic Brief Description
Brachycephalic refers to animals with a shortened skull and snout, such as Bulldogs, Pugs, French Bulldogs, Boston Terriers, and similar breeds. These conformations can make breathing more difficult, especially during stress, exercise, heat, or anesthesia. Brachycephalic airway anatomy may include narrowed nostrils, an elongated soft palate, and a smaller airway, which can affect normal airflow and increase respiratory effort.
Risks Associated with Brachycephalic Procedures
Potential risks associated with brachycephalic procedures include difficulty breathing, airway obstruction, low oxygen levels, overheating, increased anesthesia sensitivity, aspiration, delayed recovery, swelling of the airway, vomiting, and in severe cases, cardiac arrest or death. These patients may require additional monitoring, airway support, oxygen therapy, and extended recovery care.
Should be Empty:

General Admission and Consent Form