Consent for Anesthesia Form

Patient Name(Required)

First Last

Date of Procedure(Required)

MM slash DD slash YYYY

Procedures being performed:(Required)

Spay/Neuter

Dental Cleaning

Mass Removal

Biopsy Sent to Lab

Other

*Select all that apply

Any medications given within the past 2 weeks? If yes, when was last dose given?(Required)

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 (I understand that if my dog’s teeth have not been examined in the past 6 months, this estimate may not be accurate)

N/A – not having 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. *Note: We strongly recommend pre-medication with cerenia for any pets with brachiocephalic or chronic GI issues.

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.

Consent(Required)

I understand the below and consent for my pet to undergo this procedure.

I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age. I have been informed that there are certain risks and complications associated with sedation, anesthesia, and any operation/procedure. The common anesthetic reactions are lethargy/drowsiness and nausea usually lasting no more than 24 hours. If your pet has a medical condition, there is an elevated risk of complications from anesthesia. If a pet isn’t fasted properly prior to anesthesia, he or she can encounter problems like vomiting either during or shortly after being anesthetized. This can result in aspiration pneumonia, which is a very serious condition. Other complications from anesthesia, though rare, including blood clotting disorders, problems with eyesight, seizures, and kidney, liver or heart failure. I understand that during the course of the operation or procedure, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated. I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I have been informed that there are risks associated with the use of any medication. The nature of these operations or procedures has been explained to me and I understand what will be done. I accept that my financial obligations remain regardless of the outcome.

Client Name(Required)

First Last

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

Consent for Anesthesia Form

Consent for Anesthesia Form

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