Veterinary Anesthesia Consent Form

Owner Name

First NameLast Name

Owner Email

example@example.com

Owner Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Owner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet Name

Pet Age

Pet Species

Procedure(s) to be performed:

Please specify if answered "Other"

Date and time of last meal:

Date

Hour MinutesAM/PM Option

List of current medications AND supplements:

Veterinarian:

As with any procedure requiring general and/or local anesthesia, there are certain risks and serious complications or even death may result. To minimize the risk of such occurrences, we strongly recommend baseline bloodwork be performed in order to assure proper organ function, clotting ability, detect anemia or infection, and a general baseline for future reference. Please indicate if you consent to pre-anesthetic bloodwork below (select one):

As the owner of the above pet, I certify that I am over the age of 18; and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment, and hospitalization. These costs may also include minimal measures including drugs and assisted breathing.

While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein.

Would you like to have your pet microchipped today (select one):

Would you like to add post-op pain medication (select one):

Would you like to add an e-collar (cone) (select one):

Should unexpected life-saving emergency care be required I would like the hospital staff to attempt the following life saving measures (select one):

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.

Signature

For the Fix-A-Canine / Fix-A-Feline / Fix-A-Feral program Jefferson Parish residence is required. We verify residency with your photo ID. You can upload a copy here, or provide at check-in.