Name *

First

Last

Email *

Address *

Address Line 1

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City

State

Zip Code

Phone *

Patient Name *

Species *

Breed *

Age *

Sex *

Male
Female
Neutered Male
Spayed Female

PROCEDURES TO BE PERFORMED WHILE UNDER ANESTHESIA: Please check all you would like done today

Any additional Treatments or Vaccines today?

All nail trims are always complimentary while a patient is under anesthesia, if you do NOT want your pet to have a nail trim initial here

BLOOD WORK: It is our job to ensure that your pet can properly process and eliminate the anesthetic he/she is given today. Before we perform any procedure requiring anesthesia, we require pre-operative blood work on your pet. With testing, we are able to confirm that your pet's organs are functioning properly and could potentially reveal any hidden health conditions that could put your pet at risk.

PLEASE SELECT ONE: *

YES, my pet has already had blood work done.
NO, my blood work needs to be done, in hospital prior to anesthesia today.

When was blood work done? *

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me via an estimate, and I AGREE to pay such fees IN FULL at the time my pet is released from the hospital.

Understand that if your pet is found to have fleas we have the right to treat at your expense. Initial below. *

Signature *

Date *

PHONE (best number to be reached today): *

SECONDARY # (if we cannot reach you on above #) *

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Anesthesia Consent Form

Anesthesia Consent Form

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