Anesthesia Consent Form-Surgery – Town And Country Veterinary Clinic

Pet's Name:*

Date:*

Client Name:*

First Last

Daytime/ Mobile/ Home Phone Number*

Work Phone Number*

Anesthetic and surgical procedures(s) to be performed:

Pre-Anesthetic Testing

Before placing your pet under 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. Because there is always the possibility a physical exam alone will not identify all of your pet's health problems we recommend running a pre-anesthetic profile to assess your pet's organ function, prior to anesthesia. We also perform an EKG to make sure your pet’s heart is in good condition to be placed under anesthesia. Pets over 4 are required to have pre-anesthetic bloodwork

Please select your preference:*

My pet is OVER 4yrs old and I accept pre-anesthetic bloodwork
My pet is UNDER 4 yrs old and I accept pre-anesthetic bloodwork
I Decline pre-anesthetic bloodwork

When was the last time your pet had anything to eat or drink?*

When was the last time your pet last received any medication?*

List medications

Has your pet been ill lately ie had any vomiting, diarrhea, coughing or sneezing lately?*

Yes
No

If YES, please describe:

Dental radiographs are recommended with all dental procedures to fully access any disease below the gum line, With Grade III and IV periodontal disease it is required to have dental radiographs and included in your estimate, If your pet has Grade I or Grade II periodontal disease, would you like us to perform radiographs? (Cost is $75)

Would you like us to perform radiographs?*

Yes
No

I.V. Catheter/Fluids

When an animal is placed under anesthetic many problems could arise. An intravenous catheter will be placed to help in case problems were to arise while under anesthesia. Placing an I.V. catheter and running fluids will help to keep the blood pressure at a more controlled level as well as keep access to a vein available if medications or lifesaving drugs need to be administered. If your pet is having any elective surgery performed (spay, neuter, dental) an IV catheter is included in your surgery cost. **If your pet is having any non-elective procedure performed there is a $38 charge for IV catheter with fluids.

Additional Services While Under Anesthesia:

If your pet is not microchipped, we can place one while they are under anesthesia. Microchipping has helped many pets get returned to their owners when lost. Cost $48.50*

Yes
No
Already Microchipped

Please select any of the following additional services you would like performed for your animal while they are under anesthesia?

Nail Trim- $16
Express Anal Glands- $21

We offer therapeutic laser to help minimize pain and inflammation associated with the procedure. Cost $15*

Yes
No

Sometimes puppies and kittens may have retained baby teeth that require extraction in order to promote healthy growth of the adult teeth. If so, would you like them extracted?*

Yes
Please call first

If for any reason your estimate would change would you like for us to call first?*

Yes
No

(We ask that you would please be available if you check yes. It is very important to get a timely response because of your pet being under anesthesia)

Acknowledgment and Consent

I, the undersigned owner or agent of the pet identified above, certify that I am eighteen years of age or over and authorize the veterinarian(s) at to perform the above procedures(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated, My signature on this form indicates that any questions I have regarding the procedures to be performed have been answered to my satisfaction. While I accept that alt procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved, I agree to pay a deposit as deemed necessary, assume financial responsibility for the remaining fees, and provide payment via cash, credit card, or check at the time my pet is discharged from the hospital. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services.

Consent/ Signature*

I have read and fully understand the terms and conditions set forth above

Todays' Date

Authorization for Anesthesia, Surgery and Pre-Anesthetic Testing

Pre-Anesthetic Testing

I.V. Catheter/Fluids

Acknowledgment and Consent

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