Atlantic Veterinary Hospital - Anesthetic Consent Form

ANESTHETIC CONSENT FORM

Owner/Client Name(s):

Date

Pet's Name:

Species:

Surgical Procedure being performed

Please initial the following:

I am the owner or agent for the owner of the animal described above and I have the authority to execute this consent and authorize the performance of the procedure(s) or operation(s). I have been advised as to the nature of the procedure(s) or operation(s) and the risk involved.

I realize that results cannot be guaranteed. Should an emergency occur during the surgical process, do you wish for us to proceed with CPR

Yes

Food has been withheld since 10:00 PM last night and water has been withheld since 7:00 AM today.

I understand that my pet may have to be shaved on his/her leg(s) so that an IV catheter may be placed for fluid administration during anesthesia. Fluids maintain proper blood pressure to the vital organs, keeps hydration levels up, and provides intravenous access for emergency drugs should they be needed.

Other than heartworm and/or flea preventative, is your pet on any other medication(s)?

Yes

If yes, which medication(s)?

Preanesthetic Bloodwork Consent - Schedule a Tech Appointment - blood must be drawn at least 24 hours prior to Anesthesia.

Your pet is scheduled for a procedure that requires anesthesia or sedation. Our greatest concern is the wellbeing of your pet. Prior to anesthesia, a Veterinarian will perform a complete physical examination to identify any existing medical conditions that could complicate the procedure and compromise the health of your pet. There is always the possibility a physical exam alone will not identify all of your pet’s health problems. Prior to anesthesia, a pre-anesthetic blood test can be performed. Blood tests can reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future. The veterinarian recommends the following blood tests be run before anesthesia:

• CBC (Complete Blood Count) checks the immune function, hydration status, and if there is any underlying infection

• Chemistry/Electrolyte Panels check Liver and Kidney function, as well as Glucose and Electrolyte status.

Animals over the age of 8 are strongly recommended to have blood tests prior to anesthesia. Intravenous fluid therapy will be administered to help support blood pressure and process anesthetic drugs.

PLEASE CHOOSE ONE FROM THE FOLLOWING BLOOD TEST OPTIONS (please initial):

I request bloodwork to be performed prior to surgery

I decline the veterinarian recommended blood tests and request you proceed with anesthesia.

Signature

Date

Emergency Contact:

Phone