Bayens Hauk Veterinary Group - Anesthesia Consent Form

Owner Name*

First NameLast Name

Patient Name*

Breed*

Age*

Sex*

Email*

example@example.com

Like you, our greatest concern is the well-being of your pet. Before any medications are given to your pet, a pre-anesthetic examination is performed. BHVG recommends that in addition to this exam, a blood profile should be evaluated to maximize patient safety and alert the doctor to the presence of any preexisting conditions which may complicate the procedure.

Pre-anesthetic Profile: Chemistry Profile/Electrolytes: evaluates vital organ function and electrolytes to ensure that the anesthesia protocol is as safe as possible. CBC (Complete Blood Count): evaluates the numbers and characteristics on red blood cells, white blood cells and platelets.

Bloodwork ($121.82): This profile is required for pets 7 years of age and over.*

Yes: Please complete the recommended bloodwork.No: I have elected to decline the recommended bloodwork at this time.

*Please list ALL medications your pet has received today, and what time:*

What heartworm prevention is your pet on?*

Do you need a refill of your pet's heartworm prevention?*

YesNo

What flea/tick prevention is your pet on?*

Do you need a refill of your pet's flea/tick prevention?*

YesNo

Procedure(s) to be performed*

Authorization and Risk Assessment

I hereby certify that I am the owner of the above named animal or I am responsible for the above named animal and have the authority to execute this consent. I authorize sedation/anesthesia/surgery for my pet. The nature and risks of this procedure have been explained to me. I understand that some risks always exist with anesthesia/sedation, and I am encouraged to discuss any concerns I have about those risks with my veterinary hospital before the procedure(s) are initiated. I also understand and assume financial responsibility and am aware the balance is to be paid in full at the time services are rendered. Initials*

Would you like your pet microchipped today? ($85)*

YesNo

**Dental Procedure Only** I would like to be notified before extractions are performed (additional fees will apply).*

YesNo

If a critical situation arises during the procedure (please initial one):

I authorize Baeyens Hauk Veterinary Group to perform any additional diagnostics, treatments, or procedure(s) deemed necessary for medical/surgical complications, lifesaving action, or otherwise unforeseen circumstances.
Initials

I prefer no lifesaving actions to be taken if an emergency occurs (DNR)Initals

Phone Number*

Please enter a valid phone number.

Signature*