White Oak Veterinary Clinic - Anesthesia Consent Form

Surgery/Anesthesia Consent Form
Appointment Date*

MonthDayYear
Date
Owner's Name*

First NameLast Name
Pet Name*
Breed*
Sex*

MaleFemale
REQUIRED PROCEDURES to maximize your pet's anesthetic safety:
PRE-ANESTHETIC BLOOD TESTING
- Allows us to assess anesthetic risk; number of tests run depend upon the age of your pet
- Provides information about your pet’s vital organ functions, electrolytes, protein and glucose levels
- Provides a quantitative analysis of your pet’s blood cell counts
- Establishes baseline information for future reference
IV FLUID ADMINISTRATION
- Maintains blood pressure and circulation volume during anesthesia
- Allows the liver and kidneys to process anesthetic more rapidly
- In an emergency situation, an IV catheter provides a direct route for drug administration
PAIN MEDICATION will be administered/dispensed as deemed appropriate for the surgical procedure and individual patient in order to best maintain your pet’s comfort.
Consent for Procedure:
I have been advised as to the procedure and understand that complications, although very rare, may occur. These include, but are not limited to: infection, allergic reaction, hemorrhage, cardiac arrest, and possible death. Conditions may arise whereby additional procedures are required. I authorize White Oak Veterinary Clinic to do what is deemed necessary, including CPR and life-saving care and agree to pay all fees for such care.
Owner's Initials:*
I understand that surgical quotes are only estimates and are subject to change based upon complications encountered at the time of the procedure. In addition, I understand that no guarantee is implied or expressed and that adverse side effects or consequences may occur. Please initial below:*
I, the undersigned owner or authorized agent of the owner of the pet identified above, authorize the veterinarians and staff at White Oak Veterinary Clinic to perform the procedure(s) described above. I understand that some risks always exist with anesthesia and surgery, and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated.

I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. I understand that an estimate of the fees for veterinary services will be provided to me, and that I am encouraged to discuss all fees related to such care before services are rendered.
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Surgery/Anesthesia Consent Form

REQUIRED PROCEDURES to maximize your pet's anesthetic safety:

Consent for Procedure: