Pre Anesthesia Form
Your Name
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First Name
Last Name
Patient Name
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Procedure Date
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Month
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Day
Year
Date
Procedure Being Performed
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Is your pet on any medications?
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Yes
No
If yes, please list them
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***Please be sure to remove food after 10pm the night prior to the procedure
***Do not offer any food the morning of the procedure unless directed by the Veterinary Team
***Only administer medications as directed by the Veterinary Team. If you have questions regarding medications, please call our office at (540) 343-8021.
Contact Phone Number on Day of Procedure
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Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
If your pet is receiving a dental procedure, in an effort to limit the time under general anesthesia, if we are unable to reach you via phone and additional procedures are needed such as extractions, do you want us to proceed with these additional procedures before being able to speak with you (additional cost)?
Yes
No
Do you want your pet to have their anal glands expressed (additional cost)?
Yes
No
Do you want your pet to receive a microchip (additional cost)?
Yes
No
Do you want a nail trim (NO charge)?
Yes
No
Do you want sedatives prescribed for the postoperative recovery period to keep your pet calm?
Yes
No
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In the rare event that your pet experiences cardiac or respiratory arrest while under the care of Roanoke Animal Hospital, we require your consent to determine whether or not to initiate cardio pulmonary resuscitation (CPR). CPR may include chest compression, IV catheter placement and IV fluids, intubation and assisted ventilation, emergency medications, and/or electrical defibrillation. While CPR can be life saving, it does not guarantee recovery and may involve additional costs. Please indicate your preference below:
Yes- I authorize the veterinary team to perform CPR on my pet in the event ofcardiac or respiratory arrest. I understand that additional fees mayapply.
NO - I do NOT authorize CPR (DNR - Do Not Resuscitate). In the event ofcardiac or respiratory arrest, I understand that my pet will receive comfortcare only and that no resuscitative efforts will be made.
As always, we will prioritize gentle handling, close monitoring, and preventative care efforts to minimize risks and support your pet’s safety and comfort in the hospital. By signing below, I acknowledge that I have read and understand this directive and have indicated my wishes regarding emergency resuscitation.
Consent
This Addendum adds terms to the General Services Agreement (the “Agreement”)relating to the above treatment and/or anesthetic surgical procedures to be performed: I, the undersigned Client or authorized agent of the Client, certify that I am at least eighteen years of age and authorize Roanoke Animal Hospital to perform the above procedures. I understand that there are risks involved with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedures are initiated. By signing below, I confirm that any concerns or questions regarding the following information have been answered to my satisfaction: Reasonable medical and/or surgical treatment options for the Patient;● Sufficient details of the procedures to understand what will be performed by Roanoke Animal Hospital;● How the Patient will recover and the estimated recovery time;● The most common and serious complications associated with the Surgical Services;● The length and type of follow-up care and home restraint required;● The estimate of fees for all Surgical Services; and● Any necessary payment arrangements. I understand that Roanoke Animal Hospital will perform the procedures to the best of its ability, but that Roanoke Animal Hospital cannot guarantee any outcome or that the treatment will be successful. In the event that the procedure is unsuccessful or does not achieve the desired outcome, Roanoke Animal Hospital will not be liable for any damage or injury sustained by the Patient. Further, by signing below, I authorize Roanoke Animal Hospital to provide life-saving emergency care and treatment if Roanoke Animal Hospital cannot reach me.
Signature
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