Anesthesia/Surgical Consent

Current Date:

Client Name:

Address:

Phone Number:

Patient Name:

Species:

Breed:

Sex:

It is required by law that your pet is vaccinated for rabies. If you do not have proof of vaccination your pet will be vaccinated while they are here.

Anesthetic and surgical procedure(s) to be performed: {ENTERPROCEDURESTOBEPERFORMED}

Did your pet receive any medication this morning?

A

Yes

B

No

Name of all current medication(s) your pet is on:

Date and time given:

CANINES ONLY - When did your pet last receive their monthly Heartworm preventative?:

Permission for presurgical bloodwork to be run (Cost is $227.50):

A

Yes

B

No

Do you need an e-collar?

A

Yes

B

No

I, the undersigned owner or agent of the pet identified above, authorize the staff of {CLINICNAME} to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss

any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.

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. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery or treatment due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions.

A complete physical exam will be performed on your pet prior to the surgical procedure if it has been longer than 30 days since the last exam. However, this may not identify all systemic or metabolic problems. For this reason, your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia.

Phone number(s) at which owner can be reached today or tomorrow:

If I cannot be reached at the number(s) provided, I give the doctor the authority to make medical decisions for my pet on my behalf. The doctor will do their best to keep the cost of those decisions as low as possible. 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.

I give my permission

If I cannot be reached at the number(s) provided, I give the doctor the authority to make medical decisions for my pet on my behalf. The doctor will do their best to keep the cost of those decisions as low as possible. 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. I give my permission

A

Yes

B

I do not give my permission (No)

Microchips: A microchip provides the most effective method of permanent identification to re-unite you and a lost companion. Your pet’s microchip number will be registered, along with your contact information, into a data base accessible 24 hours a day, so that you can be contacted if your pet is found. Cost is $113.70 and includes the first year's registration fee with the company.

Would you like your pet to be microchipped today?

A

Yes

B

No

Dentals: If your pet is here for a dental, Do you give permission for the doctor to perform extractions if needed without speaking to you prior?

A

Yes

B

No

I have read and fully understand the terms and conditions set forth above.

Signature of Owner:

Signature