Pre-Anesthetic or Sedation Authorization Form
This consent form must be filled out completely prior to scheduled procedure. Results are submitted electronically. Alternately, you may print this form and bring it with you, completed, the morning of the procedure. If you have any questions, feel free to contact our surgical team for assistance.
Today's Date
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Month
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Day
Year
Date
Your Name
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First Name
Last Name
Your pet's name
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Anesthesia or Sedation Procedure(s) to be performed
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Scheduled date of procedure
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Month
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Day
Year
Date
Best contact number for Procedure Date
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Please enter a valid phone number.
Additional Phone Number (if you cannot be reached at the primary number)
Please enter a valid phone number.
Email
example@example.com
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Current Medications
Please list all medications, supplements, and herbs that you are currently giving your pet. This may seem redundant, but we will be cross-referencing with your pet's medical records to ensure accuracy.
Name of Medication
Dosage/Format
Amount
How Often
Last Given
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
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Waiver
I understand that some risks always exist with anesthesia/sedation and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. While I accept that all procedures will be performed to the best of the abilities of the staff at the hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed such as follow-up radiographs, re-check physical exams, and additional surgery due to postoperative complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. A complete physical examination will be performed on your pet prior to the surgical procedure. However, this may not identify all systemic or metabolic problems. For this reason, your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to sedation or anesthesia. We accept bloodwork results up to 30 days prior to the procedure.
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Understood
I have questions
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Life-Saving Measures
The attending veterinarian will make every reasonable effort to contact you regarding treatment in the case of unforeseen emergencies. In regards to life-saving efforts (Basic or Advanced Life Support), if the staff is unable to contact you:
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I give my permission to proceed with reasonable life-saving procedures (Resuscitative measures like CPR).
I do not give permission to perform life-saving procedures not already outlined in my treatment plan (DNR)
I wish to discuss this with the surgical team
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Additional Treatments & Recommendations
Some of these may or may not apply to your pet and your surgical team's recommendations. Please ask if you have any further questions about these.
Do you authorize post-operative laser therapy as described in your treatment plan to be performed on your pet during their procedure?
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Yes, I authorize laser therapy
No, I decline laser therapy
I wish to discuss laser therapy with the surgical team
During anesthesia is a great time to implant your pet’s Home Again TempScan Microchip.
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Yes, I authorize the implantation of the Home Again Microchi
No, I do not authorize the Home Again Microchip
My pet already has a microchip
I wish to discuss microchip implantation with the surgical team
If applicable: In the event of a mass removal procedure, do you authorize the specimen(s) to be sent out to the laboratory for histopathology (the diagnosis and study of diseases of the tissue)?
Yes, I authorize histopatholgy
No, I do not wish to have histopatholgy performed
I wish to discuss the histopathology with the surgical team
If applicable: We require that you keep your pet from licking, chewing, biting, scratching, rubbing, or otherwise bothering their incision or procedure area. Failure to do so may result in complications. We recommend either an Elizabethan Collar (cone) and/or Surgical Snuggy (pet onesie). Do you need one or both of these? (Understand that if you choose one of these, the surgical team may decide to utilize the other, dependent upon your pet’s unique needs)
Yes, I need an E-collar
Yes, I need a Surgical Snuggy
No, I do not need either one
I wish to discuss this with the surgical team
If applicable: If your pet is having a Dental procedure we recommend the Sanos Dental Sealant to be applied to help protect the teeth.
Yes, I authorize Sanos Dental Sealant
No, I decline Sanos Dental Sealant
I wish to discuss Sanos Dental Sealant with the surgical team
Your pet will likely be discharged with medications following the procedure(s). What format would you prefer? (We cannot guarantee all medications can be dispensed in your preferred form in all cases, but will make every effort.)
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Pill
Liquid
My pet has no preference
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External Parasites
We require that all admitted patients be free of external parasites (fleas, ticks, etc.) or they will be treated at your expense.
My pet receives
flea and tick control
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.
Last dose
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Month
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Day
Year
Date
I understand that my pet will be treated if external parasites are seen
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I understand
I have questions
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I understand that the surgery team will spend a few minutes with me to answer any additional questions I may have and get my final signature the morning of the procedure with questions about my pet’s fasting status and recent medications.
*
I understand
Submit
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