Consent for Anesthesia/Sedation

Patient Name(Required)

Client Name(Required)

First

Last

Pet Info

Age

Procedure(s) to be performed:

Has your pet been fasted (food withheld) for a minimum of 8 hours?

Yes

If you pet is being spayed today, when was her last heat cycle?

Is your pet currently on any medications or supplements?

Yes

If yes, please list the medications and last time of dose:

Surgical options:

Laser Surgery:

We have the ability to use a surgical laser rather than a scape blade for MOST routine procedures. This may decrease bleeding, swelling and post operative pain.

I elect laser surgery for my pet (Cost: $90.00)

I decline laser surgery

Microchipping:

A microchip is a means of permanent identification that is impacted under the skin. If your pet is lost, your pet may be reconnected with you via the use of a chip scanner most veterinary clinics, shelters and rescue organizations have.

I elect to have my pet microchipped (Cost: $62.10)

I decline microchipping

E-Collar/Recovery Suit:

A cone of full body suit to prevent your pet from licking their incision(s).

Accept E-Collar

Accept Recovery Suit (Cost: Based on size)

Decline

Histopathology:

The sending in of tissues/growths for further examination of disease.

Accept (Cost: $175.00)

Decline

Not Applicable

Dental Extractions:

The removal of diseased teeth.

Do anything the DVM deems necessary

Call me if exceeding the high end of my estimate

Call me prior to ANY extractions

Not Applicable

Signature(Required)

I, the undersigned, am the owner or authorized agent of the pet listed above, and am at least 18 years of age. I elect to have this pet undergo the anesthesic and surgical procedure listed above, and declare that I understand the procedure along with the associated benefits and risks (up to and including death) as discussed by my veterinarian and support staff. I have had the opportunity to have my questions regarding the procedure answered.

I authorized Country View Animal Hospital to perform a procedure requiring general anesthesia on my pet. I have been made aware of the risks involved and release Country View Animal Hospital from any legal and financial responsibilities arising from anesthetic complications. I understand that Country View Animal Hospital will do everything in their power to prevent these circumstances from occurring. By signing this form, I have heard and understand the informed consent relayed to me by the staff.(Required)

I authorized

Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, or other heroic interventions, I request that the doctor(s) at Country View Animal Hospital conduct/not conduct such medical care as indicated below. If I request such emergency procedures, I agree to be held financially responsible for veterinary services provided to my pet while staff members pursue treatment and try to reach me for further directions. Regardless of pet’s recovery or survival, I agree to be responsible for fees incurred to perform CPR in addition to other fees previously identified by the practice and agreed upon by me.(Required)

We will administer CPR treatment unless declined.

Decline

I accept that if the hospital staff is unable to reach me within 20 minutes after the initial CPR procedures, and after exercising reasonable medical judgment, determine that there is no hope for success, the staff will cease further CPR procedures. I understand that despite the best effort of the doctors and staff at Country View Animal Hospital, even the most successful CPR that may restore my pet’s life may not allow for my pet regain his/her normal mental and physical health.(Required)

I Accept

Best phone number to be reached today:

Signature(Required)

Date(Required)

MM slash DD slash YYYY

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