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

CanineFeline

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):*

Yes (Chem10 and CBC - $150)No

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.

Yes ($35 - reduced to $17.50 under anesthesia)NoMy Pet is Already Microchipped

Yes ($20-25)No

Yes ($25)No

Closed Chest Resuscitation (CPR)Do not attempt resuscitation

Yes

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.