Meyerland Animal Clinic - Anesthesia/Procedure Consent Form-new

Date*

Date

Name*

First NameLast Name

Pet's Name*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Secondary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Owner Email*

example@example.com

I am the owner or agent for the owner of the above animal and have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s) or operation(s):

I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions maybe revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) or operation(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment.

I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.

Isoflurane is one of the safest inhalant anesthetics. It allows animals to go under and recover rapidly from anesthesia even if liver, kidney, or heart disease is present, thereby reducing the toxicity in these high-risk patients. We use isoflurane exclusively for any patient that requires gas anesthesia. Anesthetics and tranquilizers do pose potential medical risks, including (though rare), but not limited to, neurological problem, paralysis, and death.

Your pet will be monitored extensively while under anesthesia with devices that measure Pulse Oximetry, Capnography, Electrocardiogram (ECG), Blood Pressure, and Body Temperature. These devices allow us to know how well your pet is doing with their surgery and increase safety and smooth recovery from anesthesia.

Pain relief in the form of injection and/or pills may be used at the discretion of your veterinarian at additional cost.

Just as when you or a loved one is admitted to a hospital or surgical facility, it is important that our Hospital doctors and staff be aware of your wishes in the event of an unexpected emergency. Typically, one either desires that all medically appropriate efforts be made to resuscitate a pet that suddenly stops breathing or suddenly has their heart stop or, in the case of a very ill animal, that no heroic efforts be made.

Please begin all medically appropriate efforts (CPR) while someone contacts me at the telephone numbers that I have provided or in person if I am on the premises of the Hospital.
Please do not resuscitate. (DNR)


I understand that, by signing this document, I give the doctors my permission to perform or not to perform CPR on my pet, according to my choice above. I also understand that I have the right to change my choice at any time if my pet's condition changes by notifying the clinician in charge.

Signature*

Blood Chemistry – REQUIRED. Initial to indicate you have read:*

A blood chemistry profile is required for all pets undergoing anesthesia. These laboratory studies test for liver, kidney, and other medical problems which may not be evident on physical examination but which may affect surgery. There is a fee for performing these tests If not done in advance.

YesNo

I would like my pet’s teeth cleaned and polished with ultrasonic scaling if needed, and at my doctor's discretion, at the time of surgery (additional fees apply). When plaque and tartar are allowed to accumulate unchecked, they eventually cause a variety of dental problems, ranging from mild discomfort and bad breath to root abscesses, difficulty eating, and tooth loss.

I also give permission for dental extractions to be done if needed. Additional charges for the extractions will be added to the bill.

Initial*

YesNo

I have been advised as to the nature of the procedures or operations and the risks involved. I realize that results cannot be guaranteed. I have read and understand this authorization and consent.

Authorized Signature of Owner or Agent*