Cat Anesthesia Consent Form

Owner's Name*

First NameLast Name

Client ID No.*

Email*

example@example.com

Phone Number*

Format: (000) 000-0000.

Alternate Phone Number*

Format: (000) 000-0000.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Pet's Name*

Pet's ID No.*

Species*

Breed*

Age*

Sex*

Procedure*

Like you, our greatest concern is the well being of your pet. Your pet will be anesthetized today and because we now your pet is a valuable member or your family, we want the procedure to go as safely as possible. We use the latest in anesthetic and monitoring techniques, however, no procedure can be completely guaranteed. We highly recommend a preanesthetic blood profile to help us place your pet in a low risk category. We recommend different blood screens depending on the age of your pet.

Initial if yes YES, Please run a mini screen recommended up to 8 years of age (10 tests).
Initial if yes YES, Please run a full survey recommended over 8 years of age (17 tests).

Has your cat had a feline leukemia test?*

YesNo

If yes, when?

If no, we strongly recommend running a feline leukemia test today. Would you like us to perform one?*

YesNo

Has your cat ever had any type of seizure activity?*

YesNo

Is your pet current on vaccinations?*

YesNo

If yes, where from?

While your pet is sedated it is also an excellent time for us to perform other services if needed. Is there anything we can check for you?

Would you like an elizbethan collar for your pet to keep them from licking their incision?*

YesNo

If we are removing a mass from your pet do you want to have the it sent to the diagnostic lab to check for cancer? (Histopathology)*

YesNo

I understand all of the above and assume all financial responsibility for this animal. I understand there are always potential risks when using anesthesia or performing surgery on an animal. I understand there is a possibility of death with any anesthetic procedure.

By checking this box I agree that all charges rendered are due at the time of service.*

I agree

Signature*

Date*

Date