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Anesthesia Consent Form (Dog/Cat)

Please fill out the form below and press submit. You will get a confirmation email of the information provided.
Owner Information:

Primary Contact

Mobile Phone

Work Phone

Email

Emergency Contact

Emergency Phone (secondary/alternative phone)

Patient Information:

Pet's Name

Species

Breed

Age

Color

Sex

Sex
A
B
C
D

Weight

Thank you for choosing our veterinary hospital for your pet’s surgical needs. The following information will be used to help our veterinary team assess your pet prior to their preoperative exam and surgery.

Has your pet had any food past 8 p.m. last night?

Has your pet had any food past 8 p.m. last night?
A
B

Has your pet ever had any convulsions or seizures?

Has your pet ever had any convulsions or seizures?
A
B

Has your pet ever had an adverse reaction to any medications, vaccines, or anesthesia?

Has your pet ever had an adverse reaction to any medications, vaccines, or anesthesia?
A
B
C

Is your pet currently taking any medications?

Is your pet currently taking any medications?
A
B

List all medications:

If yes, what time was medication last given

How was it given?

Does your pet have any chronic illnesses/diseases?

Does your pet have any chronic illnesses/diseases?
A
B

Is your pet current on vaccines and flea & heartworm prevention?

Is your pet current on vaccines and flea & heartworm prevention?
A
B

Do you want your pet microchipped while under anesthesia?

Do you want your pet microchipped while under anesthesia?
A
B
AUTHORIZATION: I represent/own the pet listed above and hereby authorize the veterinarians of the hospital to perform the above procedure(s). The nature and purpose of the procedure(s) has been explained to me and I understand that no guarantee exists as to the result or diagnosis and treatment of my pet.
I understand that my pet will be placed under general anesthesia or sedated for the necessary procedure, and understand that there are inherent risks associated with the use of general anesthesia and sedatives, including acute death.
I understand that Lange Animal Hospital and its employees are properly trained in the administration of sedatives and general anesthetics, and will properly monitor my pet during the course of the anesthesia and sedation. I give Lange Animal Hospital and its employees permission to use general anesthesia or sedation on my pet and release them from any liability should an adverse reaction occur. Should an adverse reaction occur, I give Lange Animal Hospital and its employees permission to perform all emergency procedures necessary to attempt to resuscitate and stabilize my pet. Should any problems occur, I can be reached at the phone number listed above.
I have had the fees outlined to me and agree to pay, in full, all such fees and charges at the time of discharge. These fees and charges may include those deemed necessary for medical or surgical complications or unforeseen circumstances, unless expressly declined previously on the consent form. I also acknowledge, by signing this form that I have read and understand all information included on this form.
I, the above signed owner, agent of the owner, or Good Samaritan responsible for seeking veterinary care for the pet identified, certify that I am eighteen years of age or over.

Client Signature

Signature

Date