Anesthesia and Surgical Procedure Consent Form

Welcome to the East Roswell Vet Hospital! Please fill out the Anesthesia and Surgical Procedure Consent Form before proceeding with your pet's medical journey.

Pet's Name*

When did your pet last east or drink?*

Please list any known allergies or adverse reactions to anesthetics or drugs.*

Example: Vomiting, diarrhea, swelling, hives, etc.

Is your pet on any medication including OTC medication and supplements? If so, what is the dose, frequency and the last time the medication was given?*

Please check all that apply

Mass Removal

Mass Test

Spay/Neuter

Other

Please specify the location of the mass OR explain if you selected Other:

In an attempt to minimize risks associated with anesthesia, we advise that pre-anesthetic blood work be performed, even for elective procedures. Since our pets cannot alert us to problems, these tests give us valuable information to help assess your pet’s health. If the results of the blood screening show any problems with the vital organs that would cause us to delay today’s procedure, we will contact you. If the test results are normal, they are still valuable as they provide us with your pet’s baseline normal results for comparison should your pet become ill in the future.

Do you accept the option for us to perform Pre-Anesthetic blood profiles?*

DECLINE

ALREADY PERFORMED

Chest Radiographs (Evaluating Heart and Lungs)

Do you accept the option for us to perform a Chest Radiograph?

DECLINE

ALREADY PERFORMED

Additional Treatments and Services*

Microchip

Anal Glands Expression

Nail Dremel

Cold Laster (Accelerated Post-Surgery Healing)

Nail Trim (Complimentary)

Ear Cleaning

None

Other

Consent for Anesthesia and Sedation

I acknowledge that my pet may have an underlying condition that has not been detected with diagnostic tests/tools to date, and I further understand that during the course of the procedure(s), unforeseen conditions may arise that could necessitate the performance of additional procedures. (PLEASE INITIAL)*

Please initial in the field above.

Although rare, I acknowledge that unexpected severe complications with anesthesia can occur. In addition, risks of all anesthetics may include, but are not limited to; low blood pressure, low oxygenation leading to stroke, vomiting or regurgitation leading to aspiration and pneumonia, infection, bleeding, drug reactions, blood clots, corneal abrasions and ulcers, damage to veins, arteries or nerves, brain damage, or death. (PLEASE INITIAL)*

Please initial in the field above.

To help avoid nausea and risk of subsequent vomiting under anesthesia leading to aspiration pneumonia, we recommend giving a pre-anesthetic antiemetic drug (i.e. Cerenia).*

DECLINE

Acknowledgements and Agreements

I have been informed that there are risks and complications associated with anesthesia and surgery. (PLEASE INITIAL)*

Please initial in the field above.

I release East Roswell Vet Hospital and staff from any liability relating to unforeseen complications arising from surgery and/or anesthesia. (PLEASE INITIAL)*

Please initial in the field above.

I will be available at the phone number(s) listed at all times during the day of the procedure. If the doctors and staff cannot reach me by phone, I authorize any treatment deemed necessary for the health of my pet.*

I DO

I DO NOT

I authorize treatment as deemed by the doctor over and above the treatment discussed, up to an ADDITIONAL $______________. I will only be called if such a treatment that exceeds this amount. (PLEASE LIST ADDITIONAL DOLLAR AMOUNT & INITIAL)*

Please enter a dollar amount of additional funds you are willing to spend and initial above.

If you declined the above statement, and you are requesting that we contact you prior to the performance of ANY additional treatment, you must accept the following: I fully understand that my pet will be under anesthesia longer and I accept responsibility for increased medical risk and/or cost. I also understand that if I cannot be contacted within a reasonable amount of time that my pet will be wakened from anesthesia. If I choose at a later time to have the procedure performed, it will require additional anesthesia and cost. (PLEASE INITIAL)*

Please initial in the field above.

I hereby authorize and direct the veterinarians and staff to perform the procedure(s) described above. The nature of the procedure and risks involved have been explained to me, and I realize results cannot be guaranteed. I am also aware the unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all reasonable costs incurred regarding my pet. (PLEASE INITIAL)*

Please initial in the field above.

Financial Agreement
I understand that the treatment of my pet will be conducted with due care and in accordance with the prevailing standards of competence in veterinary medicine. I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by the veterinarians and staff of East Roswell Vet Hospital. I understand that a written estimate of charges is available within reasonable time of my request, and that costs for antibiotics dispensed, pain management, additional anesthesia time and extractions may not be included on this estimate; these charges are assessed on an individual basis which may vary. In order to continue to provide the highest quality of veterinary medicine, we require payment in full at the time services are rendered. I assume financial responsibility for all charges incurred to the patient services rendered, and understand that full payment is required upon completion. I certify that I have read and understand this release, and furthermore that I assume full responsibility for all charges related to the above procedures. I am the owner (or agent for the owner of legal age) for the animal described above and I have the authority to execute this consent.

Owner's Name*

Signature*

Date*

Phone Number*

Alternate Phone Number

ADVANCE DIRECTIVE (CPR VS DNR)

I authorize the doctor to conduct CPR without my prior consent.*

I DO

I DO NOT