Pre-op under 7 years

Anesthesia & Pre-Anesthetic Testing/Surgery Consent From

Patients under 7 years
Owner's Name*

First NameLast Name
Animal's Name*
Please read carefully and sign.

Your pet is scheduled for a procedure that requires anesthesia. Like you, our greatest concern is the well-being of your pet. Therefore, we would like to take this opportunity to recommend pre-anesthetic testing and explain why it is important to the health of your pet.

Before surgery, a veterinarian will perform a complete physical examination. Because there is always the possibility a physical exam alone will not identify all of your pet's health problems, we strongly recommend a pre-anesthetic profile be performed prior to anesthesia. These tests are similar to and equally as important as those your own physician would run if you were to undergo anesthesia.

Although we use the latest and safest anesthetics available and perform a pre-anesthetic profile, it is important to understand that these precautions will not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future.

The pre-anesthetic blood tests we recommend for your pet which includes a complete blood count and 10 organ function tests can be performed at an additional cost to the surgery.

I authorize the use of anesthesia on my pet. I understand that all anesthesia involves some minimal risk to my pet, and I understand that I assume all risks providing reasonable care and precautions are followed by the attending veterinarian and staff. If any problem develops with my pet in my absence, I request that it be treated as deemed best by the staff veterinarian until I can be reached.
Choose one*

I would like to discuss pre-anesthetic testing with a veterinarian prior to making a decision.I agree to the above anesthetic release and I request that you complete the recommended testing prior to administering anesthesia to my pet.I agree to the above anesthetic release but I decline the recommended pre-anesthetic tests at this time and request you proceed with anesthesia. I understand that a medical condition may exist which would be impossible to identify during a physical exam alone. I understand that my pet's life and health could be at risk if such a condition goes undetected when my pet is placed under anesthesia.
Signature*
Phone Number*
Phone Number where I can be reached todayFormat: (000) 000-0000.
Preferred method of contact (for post surgical updates)*

Phone callText
Please answer the folowing pre-surgery questions
During the past week, has your pet exhibited any of the following symptoms: Check all that apply*

Loss of appetiteVomitingBad BreathDiarrheaCoughingSneezingExercise IntoleranceNoneOther
Has your pet ever had a seizure or convulsion? *

YesNo
List any other serious medical conditions:*
If the doctor determines that your pet's teeth need to be cleaned and loose, painful, or unhealthy teeth need to be removed, would you like it done while your pet is already under anesthesia (time permitting)? (If interested, an estimate can be provided for you.)*

YesNo
If your pet has retained deciduous teeth (baby teeth), which can cause future dental problems, would you like for them to be extracted while under anesthesia? (additional cost per tooth)*

YesNo
While sedated it is a good time to microchip your pet. Would you like to have this done today for an additional cost?*

YesNoMy pet already has one
If necessary, an elizabethan collar will be sent home with your pet. These collars are to prevent licking/chewing at the incision site and help avoid removal of the sutures and/or infection.

All surgeries (except feline neuters) will have an intravenous (I.V.) catheter put in one front leg to administer fluids during the surgery and to have access for giving medications. This will require a small amount of hair to be shaved in order to prep the area.
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Anesthesia & Pre-Anesthetic Testing/Surgery Consent From