Consent for Anesthesia Form

Patient Name(Required)

First Last

Date of Procedure(Required)

Procedures being performed:(Required)

Spay/Neuter

Dental Cleaning

Mass Removal

Biopsy Sent to Lab

Other

*Select all that apply

AT THE TIME OF DROP OFF: Any medications given within the past 2 weeks? If yes, when will last dose be given prior to drop off?(Required)

*If your pet is on chronic medications and you have not yet received specific instructions on how to administer prior to surgery, please let us know!

In the past 2 weeks has your pet had any episodes of vomiting, diarrhea, coughing, sneezing, lethargy, inappetance, or changes in drinking or peeing?(Required)

*Specify symptoms and timing.

Any other concerns for the Doctor to address today?(Required)

For spay procedures, indicate completion date of last heat cycle (if any) or N/A:(Required)

For Dental Procedures, please select one of the following:(Required)

I have received an estimate and give consent to perform whatever extractions necessary, but only within the estimated cost.

I give the Doctor permission to extract whatever teeth deemed medically necessary, even if it’s above the estimated cost.

I have not received an estimate, and am OK with the Doctor doing whatever they deem medically necessary.

Please send me a dental estimate before the procedure.

N/A – not having a dental procedure performed today.

For Mass Removals: Indicate the mass locations below, or N/A:(Required)

Based on the below, would you like an anti-nausea injection given pre-operatively?(Required)

Yes

Whatever the Doctor recommends

While recovering from anesthesia, some pets may experience nausea and/or vomiting which increases risk of aspiration and complications. If your pet is prone to nausea and vomiting, Cerenia is a powerful anti-emetic that also has pain-relieving properties that we recommended administering ~1-2 hours pre-operatively. We would give this injection here at the clinic during surgery preparation. If accepted, the cost ranges from $25-$100 depending on weight. If Cerenia is declined, and your pet experiences nausea and/or vomiting, we will treat accordingly with a short acting anti-emtic called Ondansetron as deemed necessary by the veterinarian.

Would you like any vaccines updated (if due)?(Required)

Would you like any medications or prevention refilled? If so, indicate name, QTY and current directions(Required)

Would you like us to implant a microchip?(Required)

Yes

Pet already has microchip

CVC utilizes the HomeAgain microchip system which can be used both nationally and internationally to identify pets. Every animal shelter in the area has a scanner so that found pets can be identified. Proper pet identification helps ensure your pet returns home safely. The cost of microchip implantation & registration is $55.

CPR(Required)

I elect a “Do Not Resuscitate” status in case of cardiac arrest.

I elect to have my animal resuscitated in case of cardiac arrest.

Adverse anesthetic reactions are rare but can occur. In the event that your pet should experience cardiac or respiratory arrest while being hospitalized today we will attempt resuscitative efforts/CPR unless you elect Do Not Resuscitate (DNR) above.

Client Name(Required)

First Last

Best phone number to reach you on the day of the procedure:(Required)

Consent for Anesthesia Form