Shandon Wood - Anesthesia and Sedation Consent Form

1

Client Name

Patient Name

2

Phone number where you can be reached today

Area Code

Phone Number

3

Email* This field is required.

example@example.com

4

Procedure(s)

5

Food and water withheld today?

YESNO

6

Normal eating and drinking prior to today?

YESNO

7

Any previous anesthesia?

YESNO

8

Any complications with past anesthesia?

YESNO

9

Medication(s) your pet is on

10

Was medication given today?

YESNO

11

Would you like a microchip today? ($88)

YESNO

12

Any other concerns for the doctor today?

13

FOR ALL SURGERIES

A pre-anesthetic blood panel will be performed for a fee of $95. This panel will evaluate major organ functions and help identify pre-existing problems that may not be evident on physical examination.

FOR DENTALS ONLY
While under anesthesia, the doctor will make a judgment as to whether any teeth need to be extracted based off of x-rays and examination of the teeth. I give my consent for extractions as deemed necessary and understand that I am responsible for any additional costs related to extractions.
(Initial) *

I understand that all anesthetic and surgical procedures involve some risks of complications or even death. I am encouraged to discuss any concerns I have about those risks with the veterinarian before the procedure is initiated.

I, the undersigned owner or agent of the pet identified above, authorize Shandon-Wood Animal Clinic to perform the above procedure(s). I agree to pay, in full, for services at the time they and rendered, including those deemed necessary in the event of any complications or emergencies.

14

Signature* This field is required.

Clear

15

Date* This field is required.

Date