Specialist Anesthesia Consent Form

Owner's Name*

First NameLast Name

Client ID No.*

Email*

example@example.com

Phone Number*

Alternate Phone Number*

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.

Pre-op Blood work and radiographs have been completed prior to day of surgery*

YesNo

If yes, where from?

Run a full Chemistry Panel with Complete Blood Count (17test/CBC).This is recommended for all patients having a procedure done. See Estimate for cost*

YesNo

Radiographs Pre and Post Operative may be required by our Surgical Specialist depending on type of surgery and what has been done prior to day of surgery.

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

YesNo

Is your pet current on vaccinations?*

YesNo

If yes, where from?

Is your pet current on heartworm preventative?*

YesNo

If yes, what type?

If your pet is not current or does not have a current negative test on file, we will perform a heartworm test today for anesthetic risk purposes. See Estimate for cost.

While your pet is sedated it is also an excellent time for us to perform other services if needed - nail trim, express anal glands, vaccinations, etc. Is there anything we can check for you?

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

At the discretion of our specialist be aware that your pet may need to stay overnight for Post Op. observation. Dr.Tanger will update you on your pets condition at the end of his surgery schedule usually late in the afternoon. If we need to get in contact with you, we will call the phone number(s) you provided above.

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