Authorization for Treatment and Pre-Anesthetic Testing Profile Consent Form

Authorization for Treatment and Pre-Anesthetic Testing Profile Consent Form
Client's Name*

First NameLast Name
Pet's Name*
Pre-Anesthetic/Pre-Sedation Blood Testing
Your pet is scheduled for a procedure requiring the use of anesthetic and/or sedation. We, like you, consider your pet's well-being to be our highest priority. Prior to anesthesia or sedation, we will perform a full physical examination to ensure there are no pre-existing medical conditions that may potentially cause complications.

Advances in anesthesia and anesthetic monitoring techniques have made routine procedures very safe, with low rates of complications. However, you need to understand that occasional problems can occur due to the possibility of pre-existing conditions that are not evident during routine histories and physical examinations. To minimize complications, the veterinarians and staff at this veterinary practice strongly recommend a pre-anesthetic/pre-sedation blood test. Although the blood test does not totally eliminate risk, it greatly reduces the possibility of complications by identifying conditions that may require further treatment. It also allows the veterinarian to choose the safest medications pre- and post-operatively.
Please select one of the following:*

Please perform the recommended pre-anesthetic/pre-sedation blood tests on my pet prior to administering anesthetic.I decline the recommended pre-anesthetic blood tests on my pet prior to administering anesthesia and/or sedation. I understand the increased risk of potential complications by not performing these tests before undergoing anesthesia and/or sedation. I assume full responsibility for this decision concerning my pet's health, and agree to hold the attending veterinarian and staff at this veterinary practice harmless for any untoward anesthetic, surgical, or medical complications that might have been detected and avoided had these tests been performed.I have already completed pre-anesthetic/pre-sedation blood testing for my pet within the last 60 days.
Client Authorization
I, the undersigned, owner or authorized agent of the admitted patient, hereby authorize Glamorgan Animal Clinic, and whomever they may designate as their assistants, to administer such treatment as necessary, and to perform medical and/or surgical procedures and additional procedures as are diagnostically and/or therapeutically necessary as indicated by findings during medical evaluation.

I give full and complete authority to perform the following procedure (click on "ADD MORE" to type in any additional procedure(s) to be performed):
Please select one or more of the following options that you authorize for your pet:*
I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment. I also certify that no guarantee or assurance has been made regarding the results that may be obtained. Further, I assume full financial responsibility for all charges generated by such services incurred to the patient, and that all fees must be paid in full at the time the services are performed or upon discharge from the clinic (any exception to this policy must be authorized prior to the performance of any service). In addition, I consent to release of medical information as needed.
Authorization of Additional Procedure(s)
If any additional procedure(s) (other than the procedures you outlined above) are recommended by the veterinarian, please select one of the following options:*

Please go ahead with any treatment(s) as necessary.Call me first; if you cannot reach me by telephone then proceed with any treatment(s) as necessary.Call me first; if you cannot reach me by telephone, then do not do any further treatment(s) other than the listed procedure(s). I understand that another sedation/anesthetic may be necessary at a later date with an additional expense to perform further treatment(s).
Authorization of CPR
In the rare event of an emergency situation (such as cardiac and/or respiratory arrest/failure), please indicate how you would like the veterinary team to proceed by placing your initials next to the option you choose:*

Full CPR (Cardio-Pulmonary Resuscitation)DNR (Do Not Resuscitate)
Pre-existing Medical Conditions and Current Medications
Do you have any current health concerns with your pet (for example, any vomiting, diarrhea, itchy ears, skin lesions, etc.)?*
Does your pet have any known chronic medical conditions and/or is your pet on any medication(s)?*
Has your pet ever had any previous anesthetic complications that you are aware of?*
Info for Procedure Day
List any of your pet's accessories that will brought in the day of the procedure:
Contact phone number on day of procedure*
Please enter a valid phone number.
Signature*

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Authorization for Treatment and Pre-Anesthetic Testing Profile Consent Form

Pre-Anesthetic/Pre-Sedation Blood Testing

Client Authorization

Authorization of Additional Procedure(s)

Authorization of CPR

Pre-existing Medical Conditions and Current Medications

Info for Procedure Day