Boulevard Veterinary Consent Form

Owner Name*

First NameLast Name

Owner Email*

example@example.com

Owner Phone Number*

Please enter a valid phone number.

Owner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pet Name*

Pet Species*

Pet Age*

Pet Weight*

Procedure Scheduled and any additional services that you would like performed.*

Surgical Date*

Date

In the event that the patient should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of the patient's status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion.*

I agree with CPR being performed in case of arrest.I elect a DO NOT resuscitate status in case of arrest.

The Pre-Anesthetic Blood Profiles help alert our surgeon to the presence of dehydration, anemia, infection, diabetes and/or kidney or liver disease that could complicate the procedure. These conditions may not be detected without a blood work profile thus not allowing us to identify possible concerns prior to the procedure. In addition, these tests may be useful if your pet’s health changes to develop faster, more accurate diagnoses and treatments.*

The required blood work has been performed.I am requesting that the blood work be performed today before the procedure.Feline neuter (under 2 years) old only. I elect to continue with the procedure without a pre-anesthetic blood profile. I understand the risks of anesthesia and/or surgery.The required blood work was unable to be performed due to patient temperament; I elect to continue with the procedure without a pre-anesthetic blood profile. I understand the risks of anesthesia and/or surgery.

Pet fasting before surgery is crucial as it can prevent vomiting and aspiration, which may be fatal for your furry friend. It empties the stomach and allows little to no fluid to be regurgitated from the esophagus or inhaled to the lungs. Ideally, your pet shouldn't consume food or water prior to surgery.*

I will not / have not given my pet any food or water after midnight on the night before the procedure.While my pet is under anesthesia, I elect for a microchip to be implanted.

Release for treatment: I hereby consent and authorize Boulevard Veterinary Care to administer such treatment, diagnostics, procedures, and surgery as they deem necessary for my animal. I assume full financial responsibility for the animal(s) and I hereby certify I am the owner/agent for the above named pet(s). Boulevard veterinary Care veterinarians, or staff members, will not be held liable in conjunction with procedures performed on my animal(s). The undersigned affirms the information provided above is correct and agrees to all conditions stated in this paragraph. I the undersigned do certify that I am the owner, or authorized agent of the owner of this animal(s). I hereby authorize Boulevard Veterinary, to perform medical or surgical procedures, physical examinations, anesthesia, x-ray,administer drugs, or other such treatment(s) as the veterinarian deems necessary for the patient(s) listed on this form. I agree to accept responsibility for the payment of all services rendered.*