Surgical/Anesthesia Consent And Release -

Name*

First Last

Pet’s Name*

Email*

Phone*

Time of last food/water*

: HH

MM

Agreement*

I verify that I am the owner (or authorized agent for the owner) of the above-named animal and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that the hospital personnel will be employed in the procedure(s) as directed by the veterinarian. I have been advised as to the nature of this procedure and the risks involved. I understand that there is always a risk associated with any anesthetic procedure, even in an apparently healthy animal and have discussed my concerns with the veterinarian. I understand that no guarantee or warranty can be professionally or ethically made regarding results or cure.

Anesthesia options: (Please check both)*

Injectable
Sevoflurane

Pre-anesthetic blood testing: For additional safety during the procedure, blood work is HIGHLY recommended.

Mandatory blood work is required for all animals over 5 years of age

(Accept both: The doctor will discuss which bloodwork will be performed with you prior to testing)

1.) Pre-operative Blood Screening

Accept
Decline

2.) General Health Profile

Accept
Decline

Estimate:

I request
Decline

Pain Management: I understand that pain management is used as necessary.

I authorize
Decline

Medical E-Collar:

Yes, send home with a collar
Decline, I understand I am taking the responsibility to keep my pet from damaging it’s incision.

Name

Phone*

I understand that an intravenous catheter must be placed to ensure that my pet is safe throughout the procedure, that there is a patent vein for emergency medications, and to comply with medical board standards. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from this hospital. I understand that there are no staff employed after business hours (pets needing special care may be referred to a 24-hour hospital).*

Please sign before submitting this form.

Surgical/Anesthesia Consent And Release

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Hours

Surgical/Anesthesia Consent And Release

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Hours

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