Consent for Surgery & Sedation

Full Name*

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Your Pet's Name *

Species*

Weight*

Gender

Procedure

CONSENT FORM

I understand my pet is being admitted to the hospital for the abovementioned

procedure(s). I have discussed the recommendations of the

hospital with the technician and/or doctor prior to today.

I understand that it is this hospital’s policy that all patients have preanesthetic

blood work performed. The blood panels listed below are offered

to give the doctors pertinent information about how your pet, potentially,

will handle the anesthesia. Additionally, we offer another pre-surgical

medical testing such as radiographs, EKG and ultrasound at the doctors

discretion. If these tests are recommended, we will call for your approval.

• Juvenile Wellness (Must be under 6 years)

• Pre-surgical Wellness

• General Health Profile (Complete Panel for Sick/Geriatric Patients)

A microchip can be implanted below your pet’s skin for identification

purposes. While it can be done awake, we prefer to do it while under

anesthesia due to the size of the injection syringe.

Would you like us to implant a microchip today?

YesNoDoes Not Apply, my pet is already microchipped

CPR/DNR Orders

I expect the doctors and staff of Cape Veterinary Hospital to use all

reasonable precautions regarding the safety of my pet, but I understand

there is always a potential risk with anesthesia.

If my pet experiences an emergency I would like to

PROCEED with CPR (additional costs will be incurred)DO NOT PROCEED with CPR (if your pet arrests, we will let them pass)

Your pet will be monitored by our highly trained nursing team, and while our doctors are available by phone, between the hours of 12am and 7am, there will be no doctor on-site and so cases it is recommended that patients that require more advanced care be transferred to another emergency veterinary hospital with an ICU and overnight veterinarians. By agreeing to admit your pet, you are acknowledging that CPR and advanced life-saving measures will be unavailable during these hours.

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Consent for Surgery and Sedation