Coastal Animal Medical Center Anesthesia Consent Form

Client ID*

Client Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Date of Birth*

Patient ID*

Patient Name*

Species*

Breed*

Sex*

MaleFemale

Color*

I hereby certify that I am the owner of the above-named animal, I am at least 18 years of age, and I have the authority to execute this document.*

Yes

I hereby authorize the doctors at CAMC to perform the following procedure(s):*

In addition to the procedure listed above, I would also like to have the following procedures performed for me pet:

Express Anal Glands

Yes

Pedicure

Yes

Refill the following medications

I want to pick up the following food for my pet today

CAMC requires dogs to be current on Rabies, Distemper, Bordetella and heartworm test (for anesthesia) and cats to be current on rabies and distemper to be dropped off at our facility.*

Yes, my pet is up to date on vaccines as of todayNo, my pet needs the vaccines listed below

Please list vaccines your pet needs today.

Has your pet received any medication in the past 24 hours and time given?*

Medications your pet takes, even if only as needed and last time given. (ie: pain meds, allergy meds, ear meds, HG/NG, etc):*

Has your pet experienced any signs of sickness recently (sneezing, coughing, vomiting, diarrhea, etc)?*

YesNo

Is your pet allergic or have a negative reaction to any medication/vaccination?*

YesNo

If your above answer was yes, please list allergies

When was the last time your pet ate?*

Is there anything else you would like for our doctors and staff to know about your pet?

List any belongings you're leaving with your pet today?

Your pet will be undergoing general anesthesia plus a surgical or dental procedure today. In order to recognize any underlying abnormalities your pet may have, we
require your pet to have a pre-surgical blood profile run to determine if there are any additional precautions we need to take before anesthesia and surgery. There is a
charge on your estimate for these blood tests. We hope you understand the need for these important tests.
I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending
doctor or nurse before the procedure is initiated. While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand
that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures.

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach you, do our doctors and staff have permission to provide suchtreatment and do you agree to pay for such service?*

YesNo

If you pet's heart stops beating, do you want our doctors to try to resuscitate your pet?*

YesNo

Your pet was scheduled as a drop off appointment today. Due to the nature of the procedure(s), at drop off we are not able to specify a specific pick up time. Later in
the day, one of our team members will contact you via telephone to let you know when to pick your pet up. If you haven't spoken to us directly or received a message,
please make sure you arrive at least 15 minutes before closing time to pick up your pet. Our closng time is Mon-Fri 7 pm and Sat-Sun 5 pm. If you have any
questions, please give us a call.

Signature

Coastal Animal Medical Center Anesthesia Consent Form

Patient Information

Consent