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Anesthesia Consent Form

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Medical Procedure Consent Form

Name

First

Last

How can we reach you today post-op?*

Phone

Text

Phone*

Email*

Pet's Name*

Breed*

Sex*

Procedure(s) to be performed:*

Is your pet taking any medications and/or supplements?*

Yes

If yes, please list drug(s), dose, & when dose was last given (including Heartworm prevention and Flea and Tick prevention):*

Hospitalization/Surgical Information

Preparation—The skin around the surgical area will be clipped and scrubbed with an antiseptic. We follow sterile procedures (surgical preparation, packs, and attire).

Monitoring—We further minimize anesthetic risk by monitoring heart rate and rhythm, respiration rate and quality, oxygenation, and depth of anesthesia during the procedure.

Pain Management—We will proactively manage pain associated with any procedure with appropriate pain management medications. As with any drug, side effects may be associated with their administration.

In addition to a thorough physical examination, we recommend a pre-anesthetic blood panel on all pets prior to anesthesia and require the blood panel if your pet is over 8 years of age. This blood panel evaluates organ function. Because most anesthetic drugs are metabolized or removed from the body by the liver and kidneys, it is important that these organs are working properly. These tests will be run in the clinic prior to surgery. If any of the test results are abnormal, we will discuss the results and our treatment recommendation with you. Normal results do not guarantee that your pet will not have an adverse anesthetic reaction; however, the risks are minimized when we are aware of your pet’s internal health status the day of surgery. If you have any questions regarding the blood panel or anesthesia, please ask and we will be happy to answer them.

The cost of the pre-anesthetic blood panel is $180.25

I AUTHORIZE (YES) the pre-anesthetic blood screening

I DECLINE (NO) the pre-anesthetic blood screening

I understand that during the performance of the procedure(s) that I have authorized, unforeseen complications may arise that are beyond the veterinarian’s or the clinic’s control. I hereby consent and authorize actions as are necessary in the exercise of the veterinarian’s professional judgment to address such complications

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Anesthesia Consent Form

Medical Procedure Consent Form

Hospitalization/Surgical Information

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913-724-1919

913-724-1919

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