Tequesta Veterinary Clinic - Surgery/Dental & Anesthesia Consent Form

Surgery/Dental & Anesthesia Consent Form
Owner Information
Owner's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone #*
Please enter a valid phone number.
Additional Phone #
Please enter a valid phone number.
Email*
example@example.com
Pet Information
Pet's Name*
Species*

DogCat
Breed*
Age*
Weight (if known)
Sex*

MaleFemale
Procedure Details:
Date of Scheduled Procedure*

MonthDayYear
Date
What procedure is being performed on your pet? (Select all that apply)*

SpayNeuterDentalOther
DENTISTRY PROCEDURES
If my pet has teeth that require extraction due to fracture, severe infection, loss of bone attachment (leading to mobility of tooth) or blood supply:*

I authorize the doctor to perform these procedures as deemed necessary and prudentI ask to be CONTACTED for my permission. I understand that if I cannot be reached within 10 minutes, then the doctor will go forward with appropriate treatments and I agree to any additional costs that may be associated. It is in the best interest of my pet not to stay under anesthesia longer than necessary.
Medical History
Current Medications
Allergies (Medications, Foods, etc.):
Previous Surgeries/Procedures:
Known Health Issues:
Pre-Surgery Checklist
Has your pet been fasting (no food for 8-12 hours):*

YesNo
If no, please provide details:*
Any recent changes in appetite, urination, or defecation?*

YesNo
If yes, please provide details:*
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 Tequesta 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 Tequesta 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.
CPR/DNR Preference: In the unlikely event that your pet experiences cardiac or respiratory arrest during surgery, please indicate your preference for resuscitation efforts:
- Full CPR: I authorize full cardiopulmonary resuscitation, including chest compressions, intubation, and the use of medications.
- DNR (Do Not Resuscitate): I do not authorize any resuscitation efforts. I understand that no measures will be taken to revive my pet.
Please Select One*

Full CPRDNR (Do Not Resuscitate)
Signature of Owner/Agent*
Today's Date*

MonthDayYear
Date
Should be Empty:

Surgery/Dental & Anesthesia Consent Form

Owner Information

Pet Information

Procedure Details:

DENTISTRY PROCEDURES

Medical History

Pre-Surgery Checklist

REQUIRED PROCEDURES to maximize your pet's anesthetic safety:

Consent for Procedure: