Anesthesia Soft Tissue Surgical Consent Form

All required fields are marked {*}

Pet's Name:*
Client Name:*
First Last
Client Email:*
Client Phone Number:*
Can you be reached by text if we can’t reach you by phone?*
- Yes
- No
Blood work options:
Your pet will be undergoing general anesthesia plus a surgical procedure today. In order to recognize any underlying abnormalities your pet may have, we recommend blood work to check the function of the internal organs. Knowing how well these organs’ function are an important part to the safety of your pet while under anesthesia. Please select one option below.*
- Yes, I have read the above statement and would like to perform a chemistry panel to evaluate the internal organ function, and a CBC to evaluate the red blood cells, white blood cells and platelet count to ensure clotting ability. This option is recommended to patients that are 6 years of age and older.
- Yes, I have read the above statement and would like to perform a chemistry panel to evaluate the internal organ function only. This is recommended for patients less than 6 years of age.
- No, I have read and understand the above statement and decline the pre surgical blood work.
Authorization for Anesthesia:
*
I verify I am the owner or authorized agent for the owner of the above-named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.
We require the placement of an IV catheter to administer fluids while under anesthesia. IV fluids will aid the body in stabilizing organs, stabilizing blood pressure and flushing the anesthesia out of the body more efficiently. Along with shaving the hair at the IV site, we may also shave other areas including the surgical site for surgical prepping and cleansing.
I have been advised as to the nature of this procedure to be performed and the risks involved. I also understand that there is always a risk associated with any anesthetic episode even in apparently healthy pets and have discussed by concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated, for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgement. I accept responsibility for any additional charges.*
I understand and accept
Has your pet ever had any previous reaction or issue with anesthesia?*
- Yes
- No
Signature of Owner or Agent*
Name of Owner or Agent*
First Last
Date Completed:*
MM slash DD slash YYYY
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Phone
This field is for validation purposes and should be left unchanged.

Anesthesia Soft Tissue Surgical Consent Form

Blood work options:

Authorization for Anesthesia:

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