• Valley Animal Clinic

    Valley Animal Clinic

    Anesthesia/Dental Consent Form

  • Check In Instructions:

    We like to have all of our surgery pets here between 7:45 AM and 8:15 AM on the morning of their scheduled surgery. This allows our assistants and technicians to have enough time to prepare our patients for our surgeon. Please let us know if these times do not work for you so that we can accommodate another check in time that will work for everyone.
  • Today's Date:
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  • As Owner/ Authorized Agent of the pet described above, I hereby authorize Valley Animal Clinic to perform the following procedure(s) under general anesthesia. I certify that my pet has not eaten in the last 12 hours as recommended. I give full consent to have the veterinarians of Valley Animal Clinic perform the surgical procedure listed above.

  • Has the patient been food fasted 12 hours? Water can be available overnight for your pet.

  • Surgical/Anesthesia Information:

    • All pets undergoing general anesthesia at Valley Animal Clinic are required to have pre-anesthetic blood testing to look at basic organ function and to tailor anesthetic medications used. This will also check for pre-existing medical conditions, which may increase the risk of complications during surgery.
    • An intravenous catheter will be placed to provide immediate access to your pet's circulatory system, this allows for rapid administration of drugs should an emergency situation arise. IV catheters are not placed on procedures that do not need gas anesthesia including: Feline neuters, small laceration repairs, and/or other shorten procedures.
    • Your pet will also be administered intravenous fluids to help maintain normal blood pressure, protect vital organs, and maintain proper hydration. IV fluids are not done on procedures not requiring gas anesthesia.
    • All pets undergoing surgery will receive pain injections while in the clinic. Post-operative pain management is a concern with virtually all surgical procedures. Most procedures merit at-home oral medication for several days after surgery and will be dispensed at the veterinarian's discretion.
    • All patients positive for fleas will be treated in clinic day of the procedure and the owner is financially responsible for the cost of treatment. We will let the owners know if live fleas, flea dirt, or other external parasites are found.

  • Additional Elective Procedures/Services Offered

  • Microchip Implantation ($64.00)
  • Fluoride Treatment- Included with a Dental ($18.00)- Pets that still have baby teeth do not qualify for this treatment.
  • Histopathology- for patients having a mass removed or biopsy taken ($175.00)
  • E-Collar ($11-$27 + Tax)- Velcro collars are $2-$5 more expensive based on size.
  • Post Operative Sedation Medications ($75-$85 + Tax). This is a combination of Trazodone (for post operative anxiety) and Gabapentin (for post operative pain and sedation). Some small pets (under 10 lbs) may only receive Gabapentin.
  • Flea, Tick, Heartworm Preventions (Cost is Weight Dependent)
  • Pre-Surgical Lab Work ($75-$131)- Required and included in cost for all DOG Spay and Neuter Procedures. OPTIONAL for CAT spay and neuter procedures. Pre-Surgical lab work is REQUIRED for all dental procedures. (This is included in the price)
  • Canine Heartworm Blood Testing (Must be 7 months or older) ($57)
  • Feline Triple Blood Testing (Checks for feline aids, heartworm disease and leukemia) ($66). We highly recommend to have this test performed before a Feline Leukemia vaccine is administered.
  • Deciduous (Baby) Teeth Extraction ($16/tooth)

  • DENTAL PROCEDURES ONLY- PLEASE DO NOT FILL OUT IF YOUR PET IS NOT HAVING A DENTAL PERFORMED:

    In the event that dental extractions, minor dental surgery or dental x-rays are discovered to be needed during my pet's dental cleaning, I authorize the following:
  • Dental Stage (this would have been predetermined at last visit with the veterinarian)
  • Authorization for contacting during the dental procedure:

  • Resuscitation Orders

    This needs to be answered for any and all anesthesia procedures.
  • In the event my pet's heart and/or breathing stops (cardiopulmonary arrest), resuscitation efforts according to the advanced directive below will be undertaken by the doctor(s) and/or staff of Valley Animal Clinic. I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures. While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. Please choose an option and sign below.*

  • Authorization and Risk Assessment:

  • The nature of the procedure and the potential risks have been explained to me and I understand the procedure(s) to be performed. I understand that some risks always exist with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any and all my questions have been answered to my satisfaction.

    I understand that during these procedures great care is taken to ensure my pet's health, but unforeseeable conditions may occur that necessitate an extension or variance in the procedure(s) defined above. I authorize Valley Animal Clinic to perform any additional diagnostic, treatment or surgical procedure(s) deemed necessary for medical or surgical complications or any unforeseeable circumstances. I accept responsibility for any result in additional charges. While Valley Animal Clinic provides the highest quality of anesthesia monitoring and surgical services, I understand the risks and understand that the veterinarians and hospital team will do everything possible to minimize any risks. I will not hold Valley Animal Clinic, the veterinarians or any team member liable for any complications that may arise. No warranty or guarantee has been stated or implied to me as to the results or cure afforded by these treatments or procedures. I understand that I am assuming full financial responsibility for all services rendered at the time my pet is discharged from the hospital.

  • Date
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  • Format: (000) 000-0000.
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