Anesthesia / Surgery Consent Form

Requested surgery or procedure(s):*

YesNo, please email an estimate

Pet Name*

Pet Parent's Name*

First NameLast Name

Best number where you can be reached*

Area CodePhone Number

E-mail Address

Is your pet taking any medications? (If yes, list below)*

What questions can we answer regarding your pet's procedure?

In order to recognize any underlying abnormalities your pet may have, we recommend having a pre-surgical profile run on your animal. Pre-anesthetic bloodwork checks the internal organs and blood count and is a vital part of safe anesthesia. This screening allows anesthsia to be tailored or postponed entirely if serious problems are detected. Help us provide the best level of care for your pet by choosing to perform bloodwork prior to anesthesia or sedation. Please note, patient's over 8 years of age REQUIRE bloodwork. The staff at Rickords Animal Hospital will review this with you when applicable.

I authorize bloodworkI decline bloodwork and understand there are increased risks during anesthesiaMy pet has had recent bloodwork in the last 60 days

If your pet is not current on a heartworm test (within the past 12 months) and/or has no documentation to support that he/she has been on heartworm prevention, it is important to know if they have heartworm disease as this disease can potentially interfere with anesthesia.

I authorize a heartworm testI decline a heartworm test and understand the potential increased risks during anesthesiaMy pet is current on their heartworm testMy pet is a feline (No pre-anesthetic testing)

YesNo

I verify I am the owner (or Authorized agent for the owner) of the above named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian.

I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. 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. I hearby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian's professional judgement. I accept responsibility for any result in additional charges.

I agree to be responsible for any 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. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital)

Signature*