Anesthesia Consent Form

Please fill out this form and click submit at the bottom and we will have it ready when you arrive with your pet. If you have any questions, please feel free to call us at (618)632-4615

Owner’s First name

Name

Pet’s Name Owner’s Last Name

Street Address

Address Line 2

City

State

Zip Code

Email

example@example.com

Date of scheduled procedure

Date

What procedure is your pet having done?

Dental (with or without extractions) Other procedure (if so, what?)

Did your pet eat this am?

Yes No

Age and Health Status

Young(under 7 years) and healthy

•Preanesthetic Labwork

Yes, I would like to receive the labwork No, I decline the screen & understand my pet could have an undetected/underlying condition placing him/her at anesthetic risk.

Mature(>7years) OR Pre-existing Conditions-

Our greatest concern is the well-being of your pet. Therefore, we highly recommend that your pet receive pre-anesthetic blood testing. This testing will allow us to evaluate the kidneys and liver these organs are important for anesthetic safety. We also evaluate other parameters, including a CBC and electrolytes. If an abnormality exists, you will be contacted before we proceed, to ensure the safety of your pet. In some cases, the procedure may require postponement and/or cancellation due to safety.

I understand that labwork is mandatory with any mature pet procedure

An IV catheter will be placed, and fluids given to every anesthetized pet. An IV catheter is our first line of defense in the event of an anesthetic emergency. It allows direct access to the blood stream to administer emergency medications. IV fluids also aid in the maintenance of hydration as well as managing blood pressure. Fluids also help us to “flush” the system of remaining anesthetic drugs.

Has your pet had any unusual symptoms lately (i.e.vomiting,diarrhea,inappetence, coughing,sneezing, etc)

Yes, please explain:

No

For the pet’s safety as well as our staff’s safety, any animal coming in for an anesthetic procedure are required to be up to date on vaccines. Rabies and DHLPP vaccines are required for dogs. Rabies and FVRCP Vaccines are required for cats.

Date

Any added procedures?

Nail trim (complementary) Microchip Ear cleaning Anal gland expression

Vaccines (if so, which vaccines/packages would you like?) Do not perform any additional procedures

Is your pet on any medications?

Name of medications

Dosage

# of times a day

when was the last dose given

Date/time

Date

Is your pet on a special diet EXCLUSIVELY, as in, that diet is the only diet he/she is allowed to eat? (make choices clickable)

Yes (if so, what is the name of the food): No

Yes (if so, what is the name of the food)

It is extremely important that we can reach you today for surgery updates including post-operative communication & MORE IMPORTANTLY, QUESTIONS THAT MAY ARISE WHEN YOUR PET IS UNDER ANESTHESIA. If the doctor has a question during your pet's procedure and he/she cannot get ahold of you, the doctor will use his/her best judgement regarding your pet. For instance, if your pet has a broken tooth and the doctor calls the number provided to discuss extracting the tooth, and nobody answers, the doctor will proceed with making what he/she feels is the best decision.

Please initial indicating you read the above statement

Your emergency #

Do you give us permission to text you?: Yes No

Alternate phone number

Doctors and staff are authorized to do what is necessary to resuscitate my pet and I assume all financial responsibility incurred I decline all emergency measures if complications occur

As the owner or representative of the owner, I authorize the surgery/anesthetic procedures outlined in my estimate & that payment in full is due when picking up my pet. If my pet is having a non-elective procedure, I understand that an estimate will be provided & that a deposit in the amount of 50% is due before anesthesia can be performed. Current forms of payment include Visa, Mastercard, Discover, American Express, debit, and Care Credit.

I understand that I will assume full responsibility for the care of my animal after it is released from the hospital, and that I should and will contact the hospital immediately if questions or complications develop during home care.

I do hereby acknowledge that there are no guarantees either implied or expressed that the procedures authorized will be without complications from unexpected events beyond the veterinarians’ and hospital’s control. If my pet is found to have fleas, my pet will be treated and I will incur this additional expense. Lastly, for my pet’s safety, I understand that all cats need to leave the hospital in a carrier (one can be borrowed or purchased here) & all dogs need to leave on a leash (one can be borrowed

Signature

Clear

Today’s date

Date

Please provide us with a brief description of any belongings you will be bringing – including

leashes, collars, etc.

If your pet is having his/her teeth cleaned today and/or extractions performed, please answer the 2 questions below.

Dental x-rays

Yes, perform routine full mouth radiographs I decline full mouth rads and agree to x-rays only if the veterinarian feels it necessary

Sanos Dental Sealant (details below)

Yes No

Sanos is applied after the professional dental cleaning to protect under the gumline and the ‘difficult to reach’ areas such as under the gums of the back (caudal) teeth. Sanosis a gingival dental sealant for dogs and catsthat seals the subgingival gum line (gingival sulcus) against the formation of plaque. Clinically proven and VOHC certified to last for 6 months without any takehome application required.

Please email this completed document to us at: fourpawsvet@yourvetdoc.com

Anesthesia Consent Form

Dental Cleaning Options