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Name

Pet's Name

Email Address

Phone

Today's Date

AUTHORIZATION FOR AND CONSENT TO ANESTHESIA AND SURGERY OR DIAGNOSTIC/THERAPEUTIC PROCEDURES

I hereby authorize the following procedure(s) to be performed by the admitting veterinarian, or designated associates, licensed veterinary technician and assistants: i.e. Spay/Neuter surgery, Dental Cleaning, Growth Removal, etc.)

I accept.

risks

There are risks associated with any anesthetic procedure. To help minimize the risk, a pre-anesthetic blood screen will be performed on all patients undergoing anesthesia, unless otherwise indicated by your veterinarian. Selected laboratory tests can help to assess your pet's ability to metabolize and eliminate the anesthetics we administer. In addition, the results may reveal hidden health conditions that could put your pet at risk while under anesthesia. Our hospital laboratory is fully equipped to perform these blood tests and have the results available prior to anesthesia.

NOTE: Intravenous (IV) catheters may be placed in patients undergoing anesthesia. Placement of an IV catheter allows delivery of fluids to assist in maintenance of your pet's blood pressure, hydration and to assist their organs in metabolizing the anesthetic drugs more efficiently. Additionally, in the event an emergency situation develops, an IV catheter allows rapid access for drug administration. (A small area of hair will be clipped for IV catheter placement).

Please indicate if your pet is on any medication(s) or supplements.

If yes; what drug(s) and when last given?

emergency contact

If problems unrelated to the authorized anesthetic procedure are found that require ELECTIVE correction, I may be reached at the following phone number(s).

Emergency Phone Number

Emergency Phone Number (Alternative)

Would you like to receive text message updates of your pet's status?

If the hospital staff or doctor calls and cannot reach me by phone, please do the following:

Do whatever is necessary at this time to avoid a second anesthetic procedure for additional work recommended by the veterinarian
Do not perform any additional procedures at this time to avoid a second anesthetic procedure

IF YOUR PET IS SCHEDULED FOR A DENTISTRY, PLEASE READ AND ACKNOWLEDGE BELOW

I acknowledge that if I cannot be reached during a dental procedure and tooth extraction(s) are deemed necessary for my pet's overall health, the extraction(s) will be performed.

I accept.

Verification and Approval

I understand the above anesthetic and surgical, diagnostic or therapeutic procedures may involve risk of complications, injury or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure. Furthermore, I authorize the hospital staff in an emergency situation, to follow through with such procedures as are necessary for the wellbeing of my pet on a continuing basis until further communication with me. I agree to assume financial responsibility for all routine and emergency services rendered.

Your signature below constitutes your acknowledgement, as the owner or owner's agent, that (i) you have read and agreed to the above, (ii) the procedure(s) have been explained to your satisfaction and that you have all the information that you desire, (iii) you have had the chance to ask questions, and (iv) you authorize and consent to the performance of the procedure(s) and to the administration of anesthesia.

I acknowledge and accept the terms stated above.

additional services

Please indicate if you would like to have any of the following services performed while your pet is under anesthesia:

Microchip Implantation

A small microchip is injected under the skin to permanently identify your pet should he/she become lost or stolen. Our hospital staff then registers the number with your information in a nationwide database. You will get a confirmation email with your pet's information a few days after surgery.

Yes, I would like a microchip implanted.
No, I would not like a microchip implanted at this time.
My pet already has a microchip.

Registration Email

Alternate Contact Name

Alternate Contact Phone

Any other additional services?

Fluoride Treatment to strengthen the teeth (Only beneficial to pets under 6 months of age)
Nail Trim
Retained baby teeth extracted
Other Grooming Services (ear cleaning, anal gland expression, etc.)

If any other grooming services are requested, please specify.