Anesthesia Consent Form

Your pet will receive a complimentary nail trim while in surgery today. If you would like any additional procedures done today please let your technician know at time of drop off.

Without proof of a current Rabies vaccination, patient will be vaccinated at the owner's expense. All animals admitted into the clinic must be flea free or treatment will be dispensed at owner's expense.

Add-ons the day of procedure like anal glad expression, ear cleaning and vaccines (office use only)
______________________________________
______________________________________

Owner's Name*

First NameLast Name

Best phone number to reach you at the day of procedure:*

Please enter a valid phone number.

Alternate Contact

First NameLast Name

Phone Number

Please enter a valid phone number.

Pet's Name*

Procedure to be performed:*

Mass RemovalGeneral AnesthesiaOther sedated procedure

If Mass Removal is performed, would you like it submitted for Histopathology? $124 unless otherwise stated on your estimate. This will give us more information about the mass.

YesNo

Pre-Anesthetic Testing

Pre-anesthetic testing helps to minimize risks associated with anesthesia by detecting problems prior to the administration of anesthesia. If an abnormality is found, the anesthesia protocol may be adjusted or the procedure delayed so that we may treat any underlying conditions.

PRE-ANESTHETIC COMPLETE BLOOD COUNT: $26.50 The CBC checks for signs of anemia, low platelet counts, or infection that may increase anesthetic risk.*

Yes, I would like my pet to have a pre-anesthetic CBCNo, I do not want my pet to have a pre-anesthetic CBC

PRE-ANESTHETIC CHEMISTRY PANEL: $73.50 Anesthetic agents are processed through the body by the liver and kidneys. Any disorder regarding these organs can increase your pet's anesthetic risk.*

Yes, I want my pet to have a pre-anesthetic chemistry panelNo, I do not want my pet to have a pre-anesthesia chemistry panel

Would you like INTRA-OPERATIVE FLUIDS: $43.00 An IV catheter is placed before surgery. The use of intra-operative fluids allows for immediate venous access, as well as offers another way to control blood pressure while your pet is under anesthesia.*

Yes, I want my pet to have IV fluids under anesthesiaNo, I do not want my pet to have IV fluids under anesthesia

Would you like you pet microchipped today? $50.00*

YesNo

I understand that, while the anesthetic used in this clinic is one of the safest used in veterinary medicine, no anesthesia is without medical risk. NO guarantee can be made legally or ethically to me on the outcome of any procedure performed.

I am the owner or agent of the animal described above. I have the authority to execute this consent and I am over the age of 18. I hereby authorize and direct the veterinarian of Tender Heart Animal Clinic to perform the above described procedure(s). The nature and purpose of the procedure(s), as well as the fees involved, have been explained to me. I agree to pay all such fees and charges at the time of discharge. If unforeseen conditions arise, in the judgment of the attending veterinarian, clinic will call for procedures or treatments other than those now being authorized. I authorize such procedures if reasonable efforts to contact me for further consent are unsuccessful. I understand that no guarantee exists as to the result of diagnosis and treatment of said animal.

I have read and understand this consent*

YesNo, I have questions

Signature:______________________________________ Date:____________________