Anesthesia Information and Consent

Please read the information, then fill out applicable questions about your pet.

In order to reduce the risk of exposure to COVID-19 for the staff and the other clients, we are asking that clients who are ill reschedule their appointment, or have another person bring in their pet. In the event that the visit is an emergency, and no other person is able to bring in pet, we are asking that the client inform our staff (over the phone) of the illness before interacting with them, so they can utilize additional safety protocols. ***I confirm that I have not traveled from a high risk area in the last 2 weeks, and that I am not experiencing any illness that could be related to a COVID-19 infection. *

Like you, our greatest concern is the well being of your pet. Prior to anesthetizing your pet, our doctors will perform a complete physical examination. In addition, the following measures are taken for every surgical patient.

Surgical Requirements:

An intravenous (IV) catheter is required for all anesthetized patients. Catheter placement enables us to administer IV fluids during the surgical procedure, helping prevent low blood pressure and dehydration in your pet. It also allows for the administration of any pain medications, antibiotics, or emergency drugs if necessary.

Anesthetic monitoring is performed by our trained staff, using the best technology available. Heart rate, blood pressure, electrocardiogram, core body temperature, pulse oximetry, end tidal CO2, and respiratory rate are some of the specific parameters we monitor. These vital signs are continuously assessed to help create the safest anesthetic environment possible.

The control of pain is a very important aspect of the surgical procedure. Our goal is to minimize the inherent discomfort associated with all surgical procedures. A pain free animal requires a lower level of anesthesia, increasing the safety for your pet and helping to ensure a smooth and speedy recovery. Our pain management protocol is required in all surgical patients. The medications used and length of treatment will vary based upon the procedure performed and the degree of pain involved. If needed, further out-patient medications will be prescribed for your pet to continue at home ($16 - 35). Fees for intravenous catheterization/fluids ($72), anesthetic monitoring ($47), and pain management ($48) will be added to all anesthetic procedures.

Surgical Options - please select choices below:

Blood testing (Complete Blood Count (CBC), Chemistry Panel, Electrolytes: Blood testing is advised on all pets prior to anesthesia. Many conditions, including disorders of the liver or kidneys, low grade infections, or electrolyte abnormalities can only be detected through blood testing and examination, especially before your pet shows clinical signs of illness. Detection of these conditions prior to surgery will decrease the risks associated with anesthesia. In many cases, such as geriatric or sick patients, the doctor may require blood testing prior to anesthesia. Our in-house laboratory is equipped with the latest technology to perform blood screening tests. If a problem is detected during the physical exam or on the blood work, a doctor will contact you to discuss any recommended course of action prior to surgery. Surgery will be postponed if it is deemed to be in the best interest of your pet.

Microchip implantation (HomeAgain Microchip): Microchipping is available and can easily be placed into your pet by injection. The chip is the size of a grain of rice and will permanently identify your pet in case they are ever lost. A handheld scanner identifies the number which, after registration, is permanently traceable to the owner. We will also register your pet with HomeAgain, a service which is included in the price of the implantation.

Therapy Laser: We also offer our therapy laser as a post-op service to help provide immediate pain and swelling relief at the surgical site. This quick, pain-free procedure desensitizes nerve endings and promotes faster healing of the tissues involved. This modality is used at the doctor’s discretion, as laser therapy is not advised around the eyes or in situations with suspected cancer.

Today's Date*

Name of Pet*

Anesthetic Procedure(s) to be Performed*

Primary Phone Number*

Additional Phone Number (If I cannot be reached at the primary phone number)

Email

example@example.com

In addition to the fees for I.V. catheterization, anesthetic monitoring, and pain management, the following are advised while your pet is here for surgery (please check box to authorize or decline).

I authorize pre-surgical bloodwork to be run on my pet prior to anesthesia to assess organ health. I understand that this option may be required based on my pet's age or health status and will therefore be discussed with me during my pet's stay. ($127)*

Yes, I authorize.No, I decline.

I authorize permanent identification in the form of a Home Again Microchip to be implanted in my pet while they are here for anesthesia. If your pet already has a microchip, we will not be implanting a second one. ($55)*

Yes, I authorize.No, I decline.

I authorize post-operative laser therapy to be performed on my pet during their anesthesia recovery. If yes is selected, it will still be performed at the doctor's discretion and may not be performed. ($21)*

Yes, I authorize.No, I decline.

I would like these additional procedures to be performed during my pet's visit. I understand these procedures may incur charges beyond what I was estimated for the original procedure.

Does your pet have a history of seizures or other neurologic disorder?*

YesNo

Do you have any additional concerns or questions for the anesthesia team?

Please list the medications you give your pet, and the last time they were given.

	Name and Dose	Frequency Given	Time Last Given	Date Last Given
Medication
Medication
Medication
Medication

Name*

First NameLast Name

I understand that payment for this procedure and any services at Northwood Animal Hospital is required the day they are performed. I understand that an estimate is a living document and is subject to be changed throughout the day, based on new information gathered after anesthesia is achieved (such as dental radiographs, abdominal exploratory, etc). I understand that the anesthesia team will be in contact with me during the day as new conditions arise.*

I have received an estimate for the procedure(s) within the last 60 days, and understand the potential charges.I have not received an estimate for the procedure(s), and would like one to be emailed to me. I have listed my current email address in this form.I have not received an estimate, and I do not want one. I understand that payment for today will be required at pick-up.

By signing below with my finger or mouse, I attest that I understand the procedure to be performed on my pet and have no further questions at this time. I acknowledge there may be concealed health risks to my pet and release NAH and staff from any unforeseen complications arising from anesthesia/surgery. I will be available at the phone number(s) listed below at all times during the day of the procedure. If the doctors and staff at NAH cannot reach me by phone, I agree to allow any treatment deemed necessary for the health of my pet. *

Anesthesia Information and Consent Form