• Anesthesia Procedures Consent Form

  • Owner Information

  • Format: (000) 000-0000.

  • Pet Information

  • Species:*
  • Date of Appointment*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is your pet currently on any medications?*
  • Does your pet have any allergies, or has your pet ever had any adverse reactions to medications?*
  • I prefer to receive my post-op report by:*
  • All animals admitted to this facility require proof of a current Rabies Vaccination. If proof cannot be provided, a rabies vaccination will be administered.*
  • I give consent to Gem City Veterinary Services to use photographs of my pet, without my name, for any lawful purpose, including but not limited to, social media and web content.*

  • Estimates and Options

    Dog Spay

  • A spay is a procedure performed under general anesthesia during which the veterinarian removes the animal's ovaries (ovariectomy) or ovaries and uterus (ovariohysterectomy).  The following measures are taken for every surgical patient:

    -Pre-Anesthetic Exam: A physical exam where the doctor evaluates your pet's heart, lungs, and general health status.

    -Anesthesia and Anesthetic Monitoring: Includes a pre-anesthetic sedative/pain injection, anesthetic induction, and intubation with oxygen and anesthetic gas delivery.  All pets are monitored from the beginning to the end of anesthesia by a trained veterinary assistant and vital parameter monitoring equipment. 

    -Spay Surgery: Performed by a veterinarian using sterile procedures to keep your pet safe, and modern techniques that minimize pain and trauma.  During the surgery, a cutting laser is utilized to minimize bleeding, and after the surgery, a therapy laser is applied to decrease pain and swelling and speed healing.

    -Pain Management: The pain management protocol may include injectable pain medications, local anesthetics, and take-home medication.  The medications used and length of treatment will vary based on the procedure, the degree of pain involved, and any special needs of your pet.  

    The following are estimates of the cost of a spay, depending on your pet's weight. 

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  • Pre-Anesthetic Bloodwork. With advances in anesthesia and surgery, routine procedures have been made relatively safe with a low rate of complications; nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. To assist our doctors with evaluating your pet’s anesthetic risk, we highly recommend that all pets have bloodwork performed prior to anesthesia. This includes a CBC (complete blood count) to evaluate for things such as infection and anemia, a Chemistry to evaluate internal organs such as the liver and kidneys, and electrolyte levels. Detection of these conditions prior to surgery will decrease the risks associated with anesthesia, and if a problem is detected on the bloodwork, the doctor will contact you to discuss any recommended actions prior to proceeding with anesthesia and surgery. Bloodwork may be required for any animal 6 years and older, for certain procedures, or for pets with concurrent illness or disease.*
  • Intravenous (IV) Catheter and IV Fluids. IV fluids help maintain blood pressure and organ perfusion during anesthesia, and an IV catheter allows for immediate access to a vein if the administration of emergency drugs becomes necessary.*
  • Spaying a dog while it is in heat or pregnant can cause increased bleeding during surgery, which can increase the risks associated with surgery as well as the cost. (A complicated spay will typically add ~$30 to the cost of surgery.) Please indicate your pet's heat cycle status:*
  • Deciduous (baby) teeth. Occasionally dogs (especially small breed dogs) will retain their baby teeth after their adult teeth have grown in. This can cause overcrowding of the teeth and increased tartar build up.*
  • Your pet should not be allowed to lick at their incision after surgery! A pet can very quickly and easily pull out stitches and cause serious and potentially life-threatening damage. An E-collar ("cone of shame") or Sputer ("spay-neuter" protective shirt) can help prevent licking.*
  • Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

  • Estimates and Options

    Cat Spay

  • A spay is a procedure performed under general anesthesia during which the veterinarian removes the animal's ovaries (ovariectomy) or ovaries and uterus (ovariohysterectomy).  The following measures are taken for every surgical patient:

    -Pre-Anesthetic Exam: A physical exam where the doctor evaluates your pet's heart, lungs, and general health status.

    -Anesthesia and Anesthetic Monitoring: Includes a pre-anesthetic sedative/pain injection, anesthetic induction, and intubation with oxygen and anesthetic gas delivery.  All pets are monitored from the beginning to the end of anesthesia by a trained veterinary assistant and vital parameter monitoring equipment. 

    -Spay Surgery: Performed by a veterinarian using sterile procedures to keep your pet safe, and modern techniques that minimize pain and trauma.  During the surgery, a cutting laser is utilized to minimize bleeding, and after the surgery, a therapy laser is applied to decrease pain and swelling and speed healing.

    -Pain Management: The pain management protocol may include injectable pain medications, local anesthetics, and take-home medication.  The medications used and length of treatment will vary based on the procedure, the degree of pain involved, and any special needs of your pet.  

    The following is an estimate of the cost of a spay. 

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  • Pre-Anesthetic Bloodwork. With advances in anesthesia and surgery, routine procedures have been made relatively safe with a low rate of complications; nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. To assist our doctors with evaluating your pet’s anesthetic risk, we highly recommend that all pets have bloodwork performed prior to anesthesia. This includes a CBC (complete blood count) to evaluate for things such as infection and anemia, a Chemistry to evaluate internal organs such as the liver and kidneys, and electrolyte levels. Detection of these conditions prior to surgery will decrease the risks associated with anesthesia, and if a problem is detected on the bloodwork, the doctor will contact you to discuss any recommended actions prior to proceeding with anesthesia and surgery. Bloodwork may be required for any animal 6 years and older, for certain procedures, or for pets with concurrent illness or disease.*
  • Intravenous (IV) Catheter and IV Fluids. IV fluids help maintain blood pressure and organ perfusion during anesthesia, and an IV catheter allows for immediate access to a vein if the administration of emergency drugs becomes necessary.*
  • Your pet should not be allowed to lick at their incision after surgery! A pet can very quickly and easily pull out stitches and cause serious and potentially life-threatening damage. An E-collar ("cone of shame") or Sputer ("spay-neuter" protective shirt) can help prevent licking.*
  • Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

  • Estimates and Options

    Dog Castration

  • Castration is a procedure performed under general anesthesia during which the veterinarian removes the animal's testicles.  The following measures are taken for every surgical patient:

    -Pre-Anesthetic Exam: A physical exam where the doctor evaluates your pet's heart, lungs, and general health status.

    -Anesthesia and Anesthetic Monitoring: Includes a pre-anesthetic sedative/pain injection, anesthetic induction, and intubation with oxygen and anesthetic gas delivery.  All pets are monitored from the beginning to the end of anesthesia by a trained veterinary assistant and vital parameter monitoring equipment. 

    -Castration Surgery: Performed by a veterinarian using sterile procedures to keep your pet safe, and modern techniques that minimize pain and trauma.  During the surgery, a cutting laser is utilized to minimize bleeding, and after the surgery, a therapy laser is applied to decrease pain and swelling and speed healing.

    -Pain Management: The pain management protocol may include injectable pain medications, local anesthetics, and take-home medication.  The medications used and length of treatment will vary based on the procedure, the degree of pain involved, and any special needs of your pet.  

    The following are estimates of the cost of a castration, depending on your pet's weight. 

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  • Pre-Anesthetic Bloodwork. With advances in anesthesia and surgery, routine procedures have been made relatively safe with a low rate of complications; nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. To assist our doctors with evaluating your pet’s anesthetic risk, we highly recommend that all pets have bloodwork performed prior to anesthesia. This includes a CBC (complete blood count) to evaluate for things such as infection and anemia, a Chemistry to evaluate internal organs such as the liver and kidneys, and electrolyte levels. Detection of these conditions prior to surgery will decrease the risks associated with anesthesia, and if a problem is detected on the bloodwork, the doctor will contact you to discuss any recommended actions prior to proceeding with anesthesia and surgery. Bloodwork may be required for any animal 6 years and older, for certain procedures, or for pets with concurrent illness or disease.*
  • Intravenous (IV) Catheter and IV Fluids. IV fluids help maintain blood pressure and organ perfusion during anesthesia, and an IV catheter allows for immediate access to a vein if the administration of emergency drugs becomes necessary.*
  • Deciduous (baby) teeth. Occasionally dogs (especially small breed dogs) will retain their baby teeth after their adult teeth have grown in. This can cause overcrowding of the teeth and increased tartar build up.*
  • Your pet should not be allowed to lick at their incision after surgery! A pet can very quickly and easily pull out stitches and cause serious and potentially life-threatening damage. An E-collar ("cone of shame") or Sputer ("spay-neuter" protective shirt) can help prevent licking.*
  • Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

  • Estimates and Options

    Cat Castration

  • Castration is a procedure performed under general anesthesia during which the veterinarian removes the animal's testicles.  The following measures are taken for every surgical patient:

    -Pre-Anesthetic Exam: A physical exam where the doctor evaluates your pet's heart, lungs, and general health status.

    -Anesthesia and Anesthetic Monitoring: Includes a pre-anesthetic sedative/pain injection, anesthetic induction, and intubation with oxygen and anesthetic gas delivery.  All pets are monitored from the beginning to the end of anesthesia by a trained veterinary assistant and vital parameter monitoring equipment. 

    -Castration Surgery: Performed by a veterinarian with modern techniques that minimize pain and trauma.  After the surgery, a therapy laser is applied to decrease pain and swelling and speed healing.

    -Pain Management: The pain management protocol may include injectable pain medications, local anesthetics, and take-home medication.  The medications used and length of treatment will vary based on the procedure, the degree of pain involved, and any special needs of your pet.  

    The following is an estimate of the cost of a castration.

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  • Pre-Anesthetic Bloodwork. With advances in anesthesia and surgery, routine procedures have been made relatively safe with a low rate of complications; nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. To assist our doctors with evaluating your pet’s anesthetic risk, we highly recommend that all pets have bloodwork performed prior to anesthesia. This includes a CBC (complete blood count) to evaluate for things such as infection and anemia, a Chemistry to evaluate internal organs such as the liver and kidneys, and electrolyte levels. Detection of these conditions prior to surgery will decrease the risks associated with anesthesia, and if a problem is detected on the bloodwork, the doctor will contact you to discuss any recommended actions prior to proceeding with anesthesia and surgery. Bloodwork may be required for any animal 6 years and older, for certain procedures, or for pets with concurrent illness or disease.*
  • Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

  • Estimates and Options

    Dog Oral Assessment, Dental Cleaning, and Treatment

  • An oral assessment and cleaning is a procedure performed under general anesthesia during which oral health is assessed and teeth are cleaned.  The following measures are taken for every surgical patient:

    -Pre-Anesthetic Exam: A physical exam where the doctor evaluates your pet's heart, lungs, and general health status.

    -Pre-Anesthetic Bloodwork:  Evaluates organ function, electrolytes, and blood cell counts.  Changes in bloodwork may alter how we proceed with anesthesia for your pet, so bloodwork will be run prior to your pet’s procedure.

    -Intravenous Surgical Fluids:  IV fluids support blood pressure and allow access to a vein if needed in an emergency.  

    -Anesthesia and Anesthetic Monitoring: Includes a pre-anesthetic sedative/pain injection, anesthetic induction, and endotracheal intubation with oxygen and anesthetic gas delivery.  All pets are monitored from the beginning to the end of anesthesia by a trained veterinary assistant and vital parameter monitoring equipment. 

    -Dental Radiographs:  Often diseases of the teeth are hidden beneath the gumline and therefore dental x-rays are taken to fully evaluate the health of each tooth.

    -Dental cleaning and assessment: Dental cleanings are done by a veterinarian using an ultrasonic scaler as well as hand scaling beneath the gum line and on all surfaces of all teeth.  The pocket between the tooth and gum is measured and the health of each tooth is assessed.

    The following is an estimate of the cost of the basic oral assessment and cleaning.

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  • Although every effort is made to salvage teeth, it is sometimes necessary, for the health of your pet, to remove unhealthy teeth that cannot be saved.  In these cases, oral surgery and dental extractions will need to be performed.  

    -Unfortunately, we cannot determine which teeth need to be extracted until the pet is under anesthesia and the tooth has been evaluated thoroughly during the dental cleaning and assessment and with dental radiographs.

    -Patients undergoing tooth extractions will receive appropriate pain management, which may include injectable pain medications, local anesthetics, and take-home medication.  The medications used and length of treatment will vary based on the procedure, the degree of pain involved, and any special needs of your pet.  

    -Some patients require additional take-home medications, such as antibiotics.

    As you can see from the following estimate, there can be a huge range of added cost depending on the severity of the dental disease and the number of teeth that need to be extracted.

    IF YOU HAVE NOT ALREADY RECEIVED ONE, PLEASE BE SURE TO ASK FOR A MORE SPECIFIC ESTIMATE BASED ON YOUR PET'S DEGREE OF DENTAL DISEASE.  

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  • Once your pet's dental cleaning, oral radiographs, and assessment have been performed, the doctor will determine if any additional treatments (such as tooth extractions) are recommended. Please choose one of the following to indicate your wishes.*
  • Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

  • Estimates and Options

    Cat Oral Assessment, Dental Cleaning, and Treatment

  • An oral assessment and cleaning is a procedure performed under general anesthesia during which oral health is assessed and teeth are cleaned.  The following measures are taken for every surgical patient:

    -Pre-Anesthetic Exam: A physical exam where the doctor evaluates your pet's heart, lungs, and general health status.

    -Pre-Anesthetic Bloodwork:  Evaluates organ function, electrolytes, and blood cell counts.  Changes in bloodwork may alter how we proceed with anesthesia for your pet, so bloodwork will be run prior to your pet’s procedure.

    -Intravenous Surgical Fluids:  IV fluids support blood pressure and allow access to a vein if needed in an emergency.  

    -Anesthesia and Anesthetic Monitoring: Includes a pre-anesthetic sedative/pain injection, anesthetic induction, and endotracheal intubation with oxygen and anesthetic gas delivery.  All pets are monitored from the beginning to the end of anesthesia by a trained veterinary assistant and vital parameter monitoring equipment. 

    -Dental Radiographs:  Often diseases of the teeth are hidden beneath the gumline and therefore dental x-rays are taken to fully evaluate the health of each tooth.

    -Dental cleaning and assessment: Dental cleanings are done by a veterinarian using an ultrasonic scaler as well as hand scaling beneath the gum line and on all surfaces of all teeth.  The pocket between the tooth and gum is measured and the health of each tooth is assessed.

    The following is an estimate of the cost of the basic oral assessment and cleaning.

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  • Although every effort is made to salvage teeth, it is sometimes necessary, for the health of your pet, to remove unhealthy teeth that cannot be saved.  In these cases, oral surgery and dental extractions will need to be performed.  

    -Unfortunately, we cannot determine which teeth need to be extracted until the pet is under anesthesia and the tooth has been evaluated thoroughly during the dental cleaning and assessment and with dental radiographs.

    -Patients undergoing tooth extractions will receive appropriate pain management, which may include injectable pain medications, local anesthetics, and take-home medication.  The medications used and length of treatment will vary based on the procedure, the degree of pain involved, and any special needs of your pet.  

    -Some patients require additional take-home medications, such as antibiotics.

    As you can see from the following estimate, there can be a huge range of added cost depending on the severity of the dental disease and the number of teeth that need to be extracted.

    IF YOU HAVE NOT ALREADY RECEIVED ONE, PLEASE BE SURE TO ASK FOR A MORE SPECIFIC ESTIMATE BASED ON YOUR PET'S DEGREE OF DENTAL DISEASE.  

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  • Once your pet's dental cleaning, oral radiographs, and assessment have been performed, the doctor will determine if any additional treatments (such as tooth extractions) are recommended. Please choose one of the following to indicate your wishes.*
  • Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

  • Estimates and Options

    Mass Removal
  • There is large variation in the procedures (and therefore cost) used to remove unwanted lumps and masses. Some can be removed with local anesthesia, while others require sedation and/or full anesthesia. The size and location of the mass can greatly affect the amount of time and effort (and therefore cost) required to remove the mass.*
  • We recommend all lumps and tumors that are removed be submitted for histopathology in order to identify the type of tumor and level of aggressiveness. Results are typically received in one to two weeks.*
  • Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

  • Estimates and Options

    Other
  • Please choose one of the following:*
  • Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

  • Policies, Procedures, and Authorizations

    Please read each section, click to acknowledge your understanding, and sign at the bottom
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