General Anesthesia/Sedation Consent Form

Pet's Name*

Your Name*

First NameLast Name

Date of your scheduled appointment*

Date

Phone number where I will be reachable on the day of my pet's surgery*

Please enter a valid phone number.

Contact preference today:*

Phone callText message

Emergency Contact - Please provide the name of someone you authorize to make medical decisions in your behalf if we cannot reach you at the phone number listed above.

First NameLast Name

Phone Number for Emergency Contact listed above.

Please enter a valid phone number.

Anesthesia & Sedation - Informed Consent

I understand that during anesthesia, sedation, surgery, or recovery, unforeseen conditions may be revealed that necessitate an extension of the procedure, or even procedures different than those set forth in the Treatment Plan. I understand I may request that an attempt be made to reach me by telephone for permission prior to any additional procedures or services, unless an emergency situation with my pet prevents it. In case of emergency, I hereby consent and authorize the performance of such procedures as necessary and desirable in the exercise of the veterinarian’s professional judgment to treat and maintain my pet’s health. If I cannot be reached, additional non-emergency procedures will not be performed unless I have given prior permission. I understand that I am responsible for any additional charges if additional services are provided.

I have been advised of the nature of the services and procedures included in the Treatment Plan, as well as the risks involved, including death. While I expect all procedures to be performed to the best of the staff’s abilities, I realize that medical results cannot be guaranteed.

In the case of emergency and in the event I cannot be contacted in time, I authorize Laura Monahan, DVM, and/or her agents to perform any additional diagnostic, therapeutic, or surgical procedures necessary for treating and maintaining my pet’s health and comfort. I expect Dr. Monahan and/or her agents to use reasonable precautions to ensure my pet’s safety, and I agree to pay in full for all services provided when my pet is discharged.

I have reviewed and accept the proposed Treatment Plan presented to me. I understand that a 50% deposit is due when my pet is admitted for treatment/surgery and that the remainder of the invoice is due in full at discharge. I understand the cost estimate may not be a complete representation of my final bill if additional procedures are performed.

Dogs Owners: I understand that feeding my dog a grain-free, raw, or homemade diet may increase the risk of sudden death because of a medical condition called Dilated Cardiomyopathy, a very serious - but often undetectable - heart condition that may be associated with feeding these type of diets.

Emergency Directive:*

Yes to CPR with a Financial Limitation of $315-475 (CPR, Emergency drugs, and Medical team care)Yes to CPR with a Financial Limitation of $500-715 (CPR, Emergency drugs, Intubation & oxygen support, IV catheter, and Medical team care)Do Not Resuscitate

Has your pet eaten anything (including treats) in the past 8 hours?*

YesNo

Is your pet taking any medications, vitamins, or supplements? If so, please list all medications below - this is very important to the safety of anesthesia.*

YesNo

Please list all medications, vitamins, and supplements your pet is taking.

Has your pet experienced any unreported illness or injury in the past 90 days?*

YesNo

Are you aware of any problems with anesthesia or seizures in the past?*

YesNo

May we offer your pet a light meal later today if she/he appears hungry and is medically stable?*

YesNo

Does your pet have any dietary restrictions? If so, please list below.*

YesNo

My pet cannot eat the following:

I authorize the following complimentary services for my pet while under anesthesia:*

Complimentary nail trimComplimentary anal gland expressionNo thank you, neither one

By signing below, I acknowledge that I have been advised and accept the inherent risks involved with anesthesia. I consent for my pet to receive anethesia or sedation today. While I expect all procedures to be performed to the best of the staff’s abilities, I realize that medical results cannot be guaranteed. I also understand that if complications arise, there may be additional medical care and costs required.*

Yes

Signature*

General Anesthesia or Sedation Information & Consent