Anesthesia Consent Form

Savannah's Crossing Veterinary Hospital, P.C. 2395 New Salem Hwy. Ste o Murfreesboro, TN 37128 615-410-7697 info@savannahscrossing.com

Patient Name*

Date of Procedure*

Date

List of current medications*

Procedure(s) to be performed*

Are there any additional services you would like performed while your pet is asleep? For example, clean ears, express anal glands, microchip, etc.

Phone number to reach you at today*

Would you like bloodwork (cost $130) performed prior to today's procedure?

Would you like sedatives to go home after the procedure?

Do you need an elizabethan collar (cost $12 to $20) to go home?

I understand my pet is to receive NO FOOD after 6 PM the day before surgery. Water is ok.

OWNER INITIAL*

I understand that the surgery deposit I paid will be forfeited if I cancel or reschedule my appointment with less than 24 hours notice (Monday surgeries must cancel/reschedule by Friday morning).

OWNER INITIAL*

As with any procedure requiring general anesthesia or sedation, there are certain risks that serious complications or even death may result. To minimize the risk of such occurrences, we recommend baseline bloodwork be performed in order to assure proper organ function, clotting ability, detect anemia or infection, and as a baseline for future

As the owner of the above pet, I certify that am over the age of 18; and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. As

with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services.I

acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results. Further, I understand that am financially responsible for all costs incurred during this surgery, treatment, and hospitalization

While I accept that all procedures will be performed to the best of the abilities of the staff at this facility. I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms

and conditions set forth herein.

OWNER SIGNATURE*

Date*

Date

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.

Owner Signature*

Date*

Date

Name

First NameLast Name