Anesthesia Authorization
Client Name
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Patient Name
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Date
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Month
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Day
Year
Date
Please leave us the best number to reach you at today
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Please enter a valid phone number.
Format: (000) 000-0000.
My pet was fasted twelve hours prior to admission
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Yes
No
Pre-Anesthetic Panel was completed:
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Yes
No
If Yes, please enter the date the Pre-Anesthetic Panel was completed
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Month
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Day
Year
Date
I am the owner (or agent for the owner) of the above described animal and have the authority to execute this consent.
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I consent
I hereby consent and authorize the performances of the following procedure(s) operation(s).
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I consent
Please list procedure(s) operation(s) being performed:
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I authorize the following treatments:
I authorize the use of post-operative pain analgesics.
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I consent
I authorize the use of appropriate anesthetics and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.
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I consent
I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I realize that results cannot be guaranteed.
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I consent
I understand that the above test, treatment, and procedure may vary based on individual patient needs. In some cases, additional tests or procedures may be required to reach an accurate diagnosis and achieve the best and safest treatment. Other unlisted considerations may occur as patient needs are assessed.
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I consent
I have read and understand this authorization and consent.
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I consent
I would like you to insert a microchip for identification in my pet while under anesthesia. I understand an additional fee will be added to my invoice for this service.
Yes, I would like to have my pet mircochipped and understand an additional fee will be added to my invoice for this service
Has your pet received any medication(s) this morning?
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Yes
No
If yes:
Please list medication
Signature of Owner/Agent for Owner
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Date
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Month
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Day
Year
Date
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