LMAH Veterinary Anesthetic Consent Form

Anesthetic Consent Form

Please fill out this form in entirety to ensure we can provide your pet with the best possible care.
Important

Due to the COVID-19 crisis, Lake Meridian Animal Hospital, previously Value Pet Clinic Kent may be limiting certain services and wait times may be longer than anticipated. What was routine before COVID is now time consuming and hard. Our team is working harder than ever to keep everyone safe. We truly appreciate your patience and kindness now, more than ever! Please wear a facemask at all times while interacting with our team.
Pet's Name*

First NameLast Name
Your Name*

First NameLast Name
What phone number can we reach you at while your pet is here?*

Area CodePhone Number
It is imperative that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk. If you need to leave your car, leave the parking lot, or will be otherwise occupied while your pet is here please let us know.*
Initial Above
Has your contact information changed since your last visit with us?*

YesNoUnsure (please update below)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Email*
example@example.com
Is there anyone else we can call regarding your pet while they are here today?

YesNo
Alternative Contact Name

First NameLast Name
Alternative Contact Phone

Area CodePhone Number
Reason for your pet's visit today?
If surgical, please list surgery type (i.e. Spay, Neuter, Dental Cleaning, Mass Removal etc.)
Is your pet here today for a surgical, anesthetic, or sedated procedure?*

YesNo
Is your pet here today for a dental procedure?*

YesNo
Has your pet had any food since midnight last night?

YesNoUnknown
Has your pet been vomiting or having diarrhea?

YesNoUnknown
Has your pet been coughing, wheezing or breathing hard?

YesNoUnknown
Does your pet have any allergies?

YesNoUnknown
If yes, please describe/provide more information
Has your pet ever had any adverse reaction to medication?

YesNoUnknown
If yes, please describe/provide more information
Please list any medications, supplements, topical treatments your pet has received in the past 72 hours and when they were last given:
Has your pet ever had anesthesia previously?

YesNoUnknown
Did your pet have any issues with anesthesia previously?

YesNoUnknown
If yes, please describe/provide more information
When was your pet's last dose of flea/tick prevention given?
Date Given (Please type N/A if not on a preventative)
What kind of flea/tick prevention do you use?
Name of medication - put unknown if not sure
I understand that Lake Meridian Animal Hospital will require that a treatment will be applied at the owner’s expense to any pet with evidence of fleas, flea dirt, or ticks.*
Initial Above
Is your pet current on vaccinations?*

YesNoUnknown
My pet's vaccines were administered last by:*

Lake Meridian Animal HospitalAnother veterinary clinicUnknown
Location and phone number where records can be obtained.
I understand Lake Meridian Animal Hospital requires all pets to be current on their Rabies vaccination. If proof of rabies vaccination cannot be provided, the vaccination will be given at the owner's expense.*
Initial Above
Does your pet have a microchip?*

YesNoUnknown, please scan my pet.
Would you like your pet microchipped today? (Additional Fees Apply)

YesNo
Would you like a nail trim today? (Complimentary with surgical procedures and dental cleanings)

YesNo
Does your pet have known health concerns and/or chronic disease or condition?
If yes, please tell us more. If no, please note N/A
Is there anything else we should know about your pet?
If yes, please tell us more. If no, please note N/A
Are there pictures or video that would help us with our exam today?

Browse Files
Please upload if available. Cancelof
Is there anything else you would like to discuss today?
Authorizations
I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Lake Meridian Animal Hospital. *
Initial
I certify that I am eighteen (18) years of age or older. *
Initial
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. Treatment plans above $400 must be paid in full prior to services being performed. Checks are not accepted. I understand that if I do not arrive before the clinic closes that staff will not be attending to my pet overnight and additional charges will apply.*
Initial
I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.*
Initial
I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. If necessary pets needing special care may be referred to a 24 hour hospital. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.*
Initial
We may identify additional problems during the dental procedure that could not be identified beforehand, such as broken or abscessed teeth, bone loss, deep pocketing, etc. These problems are best dealt with while your pet is under anesthesia. Please indicate how you would like for us to proceed if extractions or additional procedures are warranted:*

I authorize the veterinarian to proceed with any necessary treatment for my pet, regardless of cost.I authorize the veterinarian to proceed with any necessary treatment for my pet. I understand I will not be contacted unless the total cost of services exceeds this amount.I do not authorize the veterinarian to proceed with additional treatment without my consent. I understand if I am unable to be reached by phone, my pet will be recovered from anesthesia and an additional anesthetic procedure will be needed to correct the problem, which will be at an additional cost.
In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:*

Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred (starting range of $150-300).Please do not proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred.
I acknowledge my choice regarding resuscitation choice for my pet as noted above.*
Initial
*
Should be Empty:

Anesthetic Consent Form

Important

Authorizations