Canine/Feline Authorization for Anesthetic Procedure or surgery

Canine/Feline Authorization for Anesthetic Procedure or Surgery

Please fill form out to its entirety.
All pets admitted to the hospital must be up to date on all necessary vaccinations and routine screenings. Any outdated vaccines or routine screenings will be performed today. You should have been advised whether or not fasting was required for your pet and for how long. Your pet will be admitted, weighed, examined, prepped, and then added to inpatient or outpatient procedure schedules. Please note that it is NOT a first-come, first-serve basis. If our doctors have any questions throughout your pet's stay, they will contact you at the numbers left on this form. Once all services are complete, you will be contacted with a pick-up time, and a veterinary technician will go over a summary of instructions for home care.

Signing below indicates you have been informed that your pet requires preventive or therapeutic dental care and hereby consent to the appropriate procedures described to you by staff veterinarians at this facility. Signing below indicates the following:

You understand that there are always some risks with any anesthetic procedures, and any concerns will be expressed to the veterinarian before the procedure is initiated. The risks may include decreased blood pressure, cardiac arrhythmias, apnea, body temperature variations (hyperthermia vs hypothermia), idiosyncratic reactions to a particular drug, prolonged recovery times, and death. Additionally, there may be complications related to the surgery or procedure itself. My signature on this form indicates that any questions have been answered to my satisfaction.

South Wilton Veterinary Group only uses the safest anesthetic protocols, and patients in our care are closely monitored by a nurse-anesthetist as well as monitoring devices including pulse oximetry, ECG tracing, blood pressure, respiratory monitors, and temperature monitors. All patients undergoing general anesthesia will receive pre-operative medications and intravenous fluids during the procedure. The type of anesthesia used is dictated by the age and health as well as the scope of the procedure.

Pre-anesthetic blood tests within 30 days before the procedure are required to help ensure the safety of your pet under anesthesia. These blood tests are used to evaluate the functionality of vital organs like the liver and kidneys, which need to be healthy to metabolize the drugs used during surgery.

A pre-anesthetic ECG is also performed to evaluate the health and function of your pet's heart. If any abnormalities are present, the procedure may be altered or delayed until issues are resolved.

I understand that an estimate of fees for the above will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered. I agree to pay a deposit of 50% of the estimated fees at the time of drop-off. I assume financial responsibility for the balance of the services rendered and agree to provide payment with a credit card, cash, Care Credit, or check when my pet is discharged from the hospital.

I, the undersigned owner or agent of the pet owner identified above, certify that I am eighteen years of age or older and authorize the veterinarians at this practice to perform the above procedures.
I understand and agree to everything stated in this document. I have had all anesthetic and procedural risks explained to my satisfaction. I authorize South Wilton Veterinary Group to perform the scheduled procedure(s) on my pet.

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Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach you, the practice is authorized to perform the treatment selected below:

CPR (Cardiopulmonary Resuscitation)DNR (Do Not Resuscitate)
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In the event life saving measures are performed, you assume all financial responsibility for such care. You also understand that life-saving measures are not a guaranteed success 100% of the time.

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Today's Date

MonthDayYear
Date
Clients Name

First NameLast Name
PRIMARY phone number
Please enter a valid phone number.
SECONDARY phone number
Please enter a valid phone number.
Pets Name

First NameLast Name
What kind of procedure is being performed? (spay, neuter, mass removal, etc)
**IF YOUR PET IS HAVING A MASS REMOVED PLEASE MARK IT WITH A SHARPIE OR HIGHLIGHTER**
What time did your pet eat last?
Is your pet currently taking any medications? Please list names, concentrations, dosage, and the time last given. If your pet is not taking any medications, please write none.
Does your pet have any allergies or food allergies? If so, list them here. If none, write none.
Has your pet been eating normally? What kind of food does your pet eat? Please indicate brand, flavor, wet vs. dry, how much is fed and how often.
Has there been a change in diet? If so when?
Has your pet been drinking normally? If yes, please indicate if it is MORE or LESS than usual.
Has your pet been having any of the following symptoms lately?

If so please describe in detail in the box below.
Please explain any of the above here:
Are there any other questions or concerns you have that the veterinarian needs to be aware of?
Should be Empty:

Canine/Feline Authorization for Anesthetic Procedure or Surgery

Has your pet been having any of the following symptoms lately?