Pilchuck Equine - Anesthesia Consent Form

Client Name*

Patient Name*

Procedure and/or surgery to be performed:*

Phone number to be reached at on day of the procedure*

Please enter a valid phone number.Format: (000) 000-0000.

I attest that I am the owner or the owner’s agent of the above named animal. I certify that I am over the age of 18 and that I have permission to act as the representative of the above named animal.

I understand that the doctors and staff of Pilchuck Veterinary Hospital will take every precaution to ensure the safety of my animal. The procedure that is to be performed has been explained to me and I understand that the results cannot be guaranteed. I understand that any anesthetic procedure or surgery inherently has risks. These may include, but are not limited to, bleeding, infection, death and catastrophic injuries during recovery. By signing below I assume the risks associated with anesthesia and the above named procedure or surgery.

For anesthesia and surgery, intravenous catheters may have to be placed and the hair around the surgical areas may have to be removed. I understand that certain areas of my animal’s hair may be clipped or shaved for certain procedures and by signing below I give the staff and doctors of Pilchuck Veterinary Hospital permission to do so.

YesNo

By signing below, I acknowledge that I have had all of my questions answered regarding the above procedure and/or surgery, the risks of anesthesia, and the possibility for the development of unexpected complications.

I hereby give permission and authorization for the staff and doctors of Pilchuck Veterinary Hospital to anesthetize my pet and perform the above procedure and/or surgery.

Signature of owner or owner’s representative *

Date*

Date

Please verify that you are human*