Anesthesia/Surgical Consent Client Information Client Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Pet Information Pet Name * Species * Breed * Sex * Male Female Undetermined Surgery Details Anesthetic and surgical procedure(s) to be performed: * What time did you pet last eat? * Is your pet currently showing signs of illness? * Yes No Does your pet have any known allergies? * Has your pet had any previous reactions to anesthesia? * Yes No Not sure If your pet is a female, when was her last heat cycle? * Due to safety concerns, female dogs cannot be spayed within 8 weeks from the last day of their heat cycle. Please list any and all medications your pet is currently taking and when they were last given: * If you are unable to give dental antibiotics the morning of the procedure, please bring them with you. Pre-Anesthetic Laboratory Testing A complete physical exam will be performed on your pet prior to the surgical procedure. However, this may not identify all systemic or metabolic problems. For this reason, we strongly recommend your pet have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia. Please select one of the options listed below: * Bloodwork run in-house the morning of the procedure. Panel will be based on the life stage of your animal. I have brought my pet in within the last month and had pre-anesthetic bloodwork sent to the outside lab when my pet was not ill. I decline to have the recommended pre-anesthetic bloodwork performed and I understand the associated risks. Intravenous Catheter and Fluids It is the policy of Pets and Vets as Partners, PLLC that all patients have an I.V. catheter placed during anesthesia. Any patient 7 years or older will have an I.V. catheter placed and be given intravenous fluids during anesthesia. It is at the veterinarian's discretion whether any other patient is administered intravenous fluids based on physical exam and pre-anesthetic lab work to guarantee patient safety. You are responsible for the additional charge. Home Again Microchip I would like to take this opportunity to have my pet microchipped at a discounted price of $50.00 rather than the regular price of $65.00. These prices include the one year online registration fee for your pet. Vaccination Status All admitted animals must be current on their vaccinations and must be free of external parasites. Any animal found to have fleas or ticks will be treated at the owner's expense. The bordetella (kennel cough) vaccine is also required for dogs. If a dog has not had this vaccine within the last year it will be given at the owner's expense. Dental Procedures Only Please select an option below: I will be available during the dental procedure and WOULD LIKE to be called if extractions are necessary. *If choosing this option, please make sure you are available, because we will be calling while your pet is under anesthesia and we will not be able to perform the extractions without your consent. I will be available during the dental procedure, but I DO NOT need to be called if extractions are necessary. I will NOT be available during the dental procedure and give my authorization to extract teeth as necessary. If option one is selected above, please provide best phone number: (###) ### #### Agreement * 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. 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. Yes, I give my permission No, I do not give my permission Consent * 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 understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as deemed necessary in the veterinarian's professional judgment. I accept responsibility for any result in additional charges. 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 due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I understand that payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight. Pets needing special care may be referred to a 24 hour hospital. I have read and fully understand the terms and conditions set forth above. I, the undersigned owner or agent of the pet identified above, authorize the staff of Pets and Vets as Partners to perform the above procedure(s). Yes, I agree to e-sign this document Phone number at which the owner can be reached at today or tomorrow: * (###) ### #### Alternative phone number (###) ### #### Would you like to receive a text message with an update after your pet is awake from anesthesia? * Yes No If yes, which phone number should we text? (###) ### #### Thank you!
