Anesthesia Consent Form

Clinic Contact Information:

Benson Animal Clinic

Call/Text: (402) 453-1611

Email: bensonanimalclinic2012@gmail.com

Owner Name*

First NameLast Name

Owner Phone Number*

Please enter a valid phone number.

Emergency Contact Number*

Please enter a valid phone number.

Pet Name:*

Pet Age:

If unknown, please give an estimate of your pet's age.

Pet Species:*

CatDog

Sex:

Male IntactMale AlteredFemale IntactFemale Altered

Additional Pet Information:

Please include breed or pet size/type.

Pet Weight:

You may add an estimate of your pet's weight if you're unsure.

Previous Medical History:

Please include any relevant history such as vaccinations, previous veterinary records, etc.

Requested Procedure(s):

Please include any additional services requested such as vaccinations, microchip, or a nail trim. *There is a charge for any additional services provided. If complications arise, there may be an additional charge.

We recommend a Preanesthetic Panel (PAP) for pets 7 years and older. Bloodwork is not required, but highly recommended in order to ensure your pet will do well under anesthesia.

Bloodwork Panels are as follows:

Preanesthetic Panel (PAP): $100 - PAPs are minimal bloodwork panels that check the kidney and liver values of your pet. This option is recommended when undergoing anesthesia.

Comprehensive/Hematology (CBC/COMP): $225 - CBC/COMPs check all of your pet's functions, allowing us to ensure your pet is healthy and doing well. This bloodwork panel is not necessary to undergo anesthesia. This bloodwork covers White/Red Blood Cell Counts, Kidney and Liver Values, and many other functions of the body.

Bloodwork is an additional charge and separate from any surgery price quotes.

Bloodwork Options:

Decline BloodworkPAPCBC/COMPI would like to discuss bloodwork in-person.

The nature of all procedures listed above and the risks and potential complications have been explained to me. I understand what will be done and understand that if complications arise the performance of additional procedures may be necessary. I have also been informed of alternate options to the above procedures.

I authorize the use of appropriate anesthesia and pain medications as needed before, during, and after the procedure. I have also been informed that there are inherent risks and complications associated with the use of any medication.

I hereby acknowledge I have been given an estimate of all charges and accept financial responsibility for the care of this animal. I also understand that all charges will be paid at the time of release and that a deposit fee may be required.

By signing this document, I also understand that any complications or further services rendered that there will be an additional cost and accept financial responsiblity for any additional charges.

Signature*

Date*

Date