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
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First Name
Last Name
Your Name
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First Name
Last Name
What phone number can we reach you at while your pet is here?
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-
Area Code
Phone 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.
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Initial Above
Has your contact information changed since your last visit with us?
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Yes
No
Unsure (please update below)
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Cell Phone
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Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
Alternate Phone
-
Area Code
Phone Number
Email
*
example@example.com
Is there anyone else we can call regarding your pet while they are here today?
Yes
No
Alternative Contact Name
First Name
Last Name
Alternative Contact Phone
-
Area Code
Phone 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?
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Yes
No
Is your pet here today for a dental procedure?
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Yes
No
Has your pet had any food since midnight last night?
Yes
No
Unknown
Has your pet been vomiting or having diarrhea?
Yes
No
Unknown
Has your pet been coughing, wheezing or breathing hard?
Yes
No
Unknown
Does your pet have any allergies?
Yes
No
Unknown
If yes, please describe/provide more information
Has your pet ever had any adverse reaction to medication?
Yes
No
Unknown
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?
Yes
No
Unknown
Did your pet have any issues with anesthesia previously?
Yes
No
Unknown
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.
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Initial Above
Is your pet current on vaccinations?
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Yes
No
Unknown
My pet's vaccines were administered last by:
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Lake Meridian Animal Hospital
Another veterinary clinic
Unknown
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.
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Initial Above
Does your pet have a microchip?
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Yes
No
Unknown, please scan my pet.
Would you like your pet microchipped today? (Additional Fees Apply)
Yes
No
Would you like a nail trim today? (Complimentary with surgical procedures and dental cleanings)
Yes
No
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.
Cancel
of
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.
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Initial
I certify that I am eighteen (18) years of age or older.
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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.
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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.
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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.
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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:
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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:
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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.
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Initial
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