Surgery/Anesthesia Consent Form

Client Information

Owner's name:*

Address:*

Email*

example@example.com

Home Phone:*

Please enter a valid phone number.

Cell Phone:*

Please enter a valid phone number.

Emergency Phone:

Please enter a valid phone number.

Patient Information

Pet's name:*

Species:*

Breed:*

Sex:*

Weight:*

Color:*

Birthdate or age:*

Date and time of last meal:*

List of current medications:*

Procedure(s) to be performed:*

As with all anesthetic, treatment, and/or surgical procedures, we want you to understand there are some risks inherent in these services. To minimize the risk, we recommend baseline bloodwork be performed in any animal but especially for animals age 7 or older. This helps us assess proper organ function, clotting ability, detection of anemia or infection, and it gives us a baseline for future reference. The complete blood count (CBC) is a more sensitive indicator of disease, evaluating white blood cells (WBCs), red blood cells (RBC's) and platelets. The chemistry evaluates the liver, kidneys, pancreas, electrolytes, and the endocrine systems. Monitoring these parameters in patients is helpful during anesthesia, minimizing the risk of arrhythmias and hypotension and facilitating smoother patient recovery. *****Additional cost ranges from $35.00-$180.00*******

Pre Anesthesia Baseline (CBC, Chem 10, SDMA, & Electrolytes) $105.00Chem 10 +SDMA/T4 , CBC (Baseline) $149.33Chem 17 + SDMA/T4, CBC (Baseline +7chem) $171.01Chem 22 + SDMA/T4, CBC (Baseline +7chem +electrolytes) $191.21I am declining bloodwork.

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

Closed Chest Resuscitation including drugs and CPR assisted breathing (Additional cost ranges from $50.00-$200.00)Do not attempt resuscitation

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 with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results.

I acknowledge that there is no Payment Plan available & I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.

Owner Signature:*

Date*

Date

Surgery/Anesthesia Consent Form

Consent Information