Anesthesia Consent Form

Owner's Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Pet's Name(Required)

Age(Required)

Sex(Required)

Male

Female

Doctor authorized to perform the surgery:(Required)

Procedure(s) to be performed:(Required)

1. I hereby authorize the doctor listed above and whomever he/she designates as their assistants to perform the procedure(s) or surgeries specified above.

2. It has been explained to me that conditions may arise during the procedure whereby a different procedure or an additional procedure may need to be performed, and I authorize my veterinarian to do what he/she feels is needed and necessary.

3. I have been advised as to the nature of the procedures and the risks involved. I understand that complications including but not limited to infections, cardiac arrest, and death could result. I acknowledge that no guarantee has been made as to results or cure.

Pre-Anesthetic Blood Testing:

Like you, our greatest concern is the well being of your pet. Before putting your pet under anesthesia, we will perform a physical examination. However, many conditions, including disorders of the liver, kidneys and blood, may not be detected unless blood testing is performed. These tests are similar to those your own physician would run. Such tests are especially important before anesthesia. In addition, the results of these tests will serve as reference values for future use should your pet become ill. We strongly recommend that all patients receive a blood screen before such procedures. The blood screens can be performed and the results available the same day as the anesthesia.

Please select a blood screening for your animal:

Profile #1 - Healthy Patients Under 2 Years of Age - $110

Profile #2 - Healthy Patients 2-7 Years of Age - $130

Profile #3 - Patients Over 7 Years of Age or Patients with Existing Medical Conditions - $169

Do you accept or decline the blood screening?(Required)

Yes, I want my pet to have a blood screen performed prior to anesthetic administration.

No, I decline this blood screen, I understand that there may be undiagnosed conditions which may complicate anesthetic procedures.

Would you like to have your pet's surgery performed with laser?(Required)

Yes

Would you like to have your pet microchipped while under anesthesia? (Cost = $59.99)(Required)

Yes

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Pre-Anesthetic Blood Testing:

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