Anesthesia Surgical Consent

Client Name*

First NameLast Name

Email

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Patient Name*

Breed*

Color*

Sex*

MaleFemaleMale NeuteredFemale Spayed

Procedure to be performed:*

Any medical issues staff should be aware of:*

What medications or supplements does your pet take?*

Is your pet current on heartworm prevention? if yes, which one?*

Is your pet current on vaccinations?*

Is your pet current on flea prevention? If yes, which one? Please note that any pet with active external parasites will be treated and billed appropriately.*

I understand that the doctors and staff will use all reasonable precaution against injury, escape or death of my pet. Anesthesia involves some risk to my pet; therefore, blood testing is recommended before general anesthesia. The anesthetic agent is removed from the body by the liver and kidneys so it is important to know that these organs are functioning properly. Bloodwork helps us to make this determination. Bloodwork may be required on some patients due to special circumstances.

Pre-anesthetic labwork*

I ACCEPT pre-anesthetic bloodwork and the COST associated with itI DECLINE pre-anesthetic bloodwork.

Pain management*

I ACCEPT pain medication and costs associated with itI DECLINE pain medication

I have not given my pet food or water after midnight before the procedure unless otherwise advised by my doctor. I understand this is important for anesthesia safety.*

I agreeI disagree

Phone number where I may be reached today in case of emergency*

I prefer to receive a text message for updates*

YesNo

Date*

Date

Signature*