Surgery and Anesthesia Consent Form - Akin Hills Pet Hospital

Client Name*

First Last

Email*

Phone *

Date*

Patient Name*

Species*

Breed*

Color*

Sex*

MaleFemale

What is the approximate age of your pet?*

Weight*

Today’s Phone Number: (This number needs to be reliable to reach you while your pet is under anesthesia.)*

We agree to fast our pet overnight, with no food after 10 PM (can offer water)*

Yes

Does your pet have allergies?*

YesNo

Allergies

Is your pet on any medications?*

YesNo

Please list medications your pet is on.

Is your pet allergic to any medications?*

YesNo

Please list medications your pet is allergic to

Is your pet on any supplements (joint supplements, CBD, etc.)?*

YesNo

If yes, please list below

Has your pet been coughing, wheezing or sneezing?*

YesNo

As the owner or agent of the animal listed above, I hereby give consent for Akin Hills Pet Hospital to perform surgery on my pet.*

If your pet is to be anesthetized, be assured that advances in anesthesia and surgery have been made for routine procedures relatively safe with a low rate of complications. Nonetheless, occasionally problems can arise due to pre-existing conditions that may not be noticed during the pre-anesthetic examinations. To avoid these problems, we recommend all pets be screened prior to anesthesia by the following laboratory tests.

1. Pre-anesthetic Blood Screening: packed red blood cell.

2. IV catheter and Fluids: aids in adequate blood pressure and gives immediate access to the vein if an emergency arises.

The following options are optional. They will be performed (and you will be charged) unless you refuse them and initial below.

Prep or Comp and/or CBC screens organ functions and/or a complete blood count*

YesNo

Heartworm Test (dogs, if not up to date or on heartworm preventative)*

YesNo

Teeth Extractions (With radiographs prevents over crowding)*

YesNo

Home Again Microchip (Aids in your pet being returned to you if your pet gets lost)*

YesNo

We strongly recommend purchasing and placing an Elizabethan Collar (cone collar) on your pet until his/her incision is fully healed. (We understand that constant supervision of your pet during recovery at home can be difficult. Therefore, the use of an Elizabethan Collar, while not a guarantee against post-operative complications, may help prevent self-trauma (licking and chewing at their own incisions), a significant source of problems associated with the incision)*

YesNo

Do you consent to a 3-5 minute ultrasound on your pet? (We are currently learning a new technology and trying to become more knowledgeable and comfortable looking at normal anatomy on ultrasound. This would be at no extra charge to you and would only be done if your pet is stable under anesthesia)

YesNo

Rabies Vaccine: (a current rabies vaccine is required for all pets at our clinic)*

I’m aware of this requirement and have proof of vaccination or I am giving Akin Hills Pet Hospital authorization to give the vaccination.

I understand that during the performance of this procedure, unforeseen conditions may be revealed that can delay or change the procedure set forth above. I expect Akin Hills Pet Hospital to use reasonable care and judgment in performing the procedure. The nature of the procedure and the risks involved, including death, has been explained to me and I realize results cannot be guaranteed therefore, I will not hold Akin Hills Pet Hospital liable if something happens to my pet. I am also aware that unforeseen events resulting from the procedure will not relieve me from any obligation to all reasonable costs incurred regarding my animal.*

Yes, I do understand.

Signature*