Anesthesia Admission Form

Anesthesia Admission Form

Please fill out this form to its completion if your pet is being (or may be) anesthetized today; this includes dental procedures, surgery, sedated nail trims etc.
Owner Name (First, Last) *
Patient Name *
Today's Date *

Month Day Year
Owner Phone Number *
Owner Email *
What DATE did your pet last eat? *

Month Day Year
Date
What TIME did your pet last eat? *

: Hour Minutes AM/PM Option
Any comments about their last meal?
Please list ALL surgical procedures that you are expecting to be performed on your pet. (If applicable, please specify location of any masses to be removed) *
Would you like your pet to have a Home Again microchip implanted? (Additional $65 cost) *

Yes No
Is there anything else that you would like performed today while your pet is with us? (Please include any additional instructions for the day of surgery) *
Does your pet have any allergies? *

Yes No
If YES, please specify below *
Is your pet on any current medications? *

Yes No
If YES, please list below (include name of medication, and frequency given)
Contact numbers for DAY OF SURGERY. We require at minimum TWO contact numbers, please list the PRIMARY contact below *
SECONDARY Contact Number *
Additional Notes To Doctor (if any)
Authorization For Anesthetic Procedure And/Or Surgery

I, being responsible for the above-described animal, have the authority to grant you my consent to receive, prescribe for, treat and/operate upon my pet listed above. I consent to the administration of such anesthesia as may be deemed proper by the doctor. I consent to the above described treatment and/or surgery. I acknowledge that no assurance or guarantee has been made of the results of surgery or treatment and that risks and probabilities of complications exist in any surgical or medical treatment. I understand that conditions not known may make it advisable that other surgery or treatment be done and I authorize them if they are deemed advisable. I understand that if the animal is not current on vaccination, this will be done upon hospitalization and added to the cost of the above-described procedure. All fees shall be paid when the pet is released from the hospital. The hospital will use all reasonable precautions against injury, escape or demise of the animal but will not be held liable or responsible in any manner whatever or any circumstances on account of the care, treatment or safekeeping of the animal described above, as it is thoroughly understood that I assume all risks. AFTER CAREFULLY READING THE ABOVE, I HAVE SIGNED IN AGREEMENT:
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Anesthesia Admission Form

Authorization For Anesthetic Procedure And/Or Surgery