Surgery Consent Form Kildaire

Owner Name *

First Name Last Name

Client ID

Animal Name *

Breed *

Age *

Sex *

Last Meal Eaten *

Special Diet or Dietary Restrictions

Current Medications and Last Time Administered

Please List Any Known Allergies or Adverse Reactions To Medication(s)

Procedure To Be Performed *

Please Select All Of The Below *

I give my permission for to be anesthetized for the above listed procedure I understand that in order for my pet to undergo anesthesia and stay in the hospital they must be current on all vaccines and must have recent blood work to assess organ function. I understand that even with excellent care and precautions, rare adverse reactions or events can occur with anesthesia. These events are extremely rare and can include but are not limited to: cardiac arrest, respiratory arrest, and death. I understand that tissue healing is variable and that specific results cannot be guaranteed I understand that an IV catheter will be placed and a small area on the leg will be shaved for placement.

Most surgeries require that an Elizabethan collar be worn by the patient for 10-14 days post-surgically to prevent self-trauma. There are a few options to choose from but not all are appropriate for some procedures. Please note your preference *

Plastic collar ($15.45) Inflatable neck collar ($23.65) Medical Protective shirt ($28)

MICROCHIP: Would you like your pet to have a microchip placed while under anesthesia? ($66.40 with surgery) *

Yes No Already Have One

Phone number where you can be reached between 8:30 a.m. and 3:30 p.m *

Please provide email address or cell number if you would also like an email or text update when your pet is awake

Signature

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