Home Anesthesia/Surgery Consent Form

Anesthesia/Surgery Consent Form

"*" indicates required fields

Client First Name*

Client Last Name*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Phone*

Pet Name*

Species*

Breed*

Sex*

Male

Female

Color*

Markings*

Birth Date*

Has your pet eaten since bedtime last night?*

Yes

Has your pet had water since midnight last night?*

Yes

Is your pet currently taking any medications?*

Yes

List medication name, time of last dose and amount given

Primary Contact Name*

Primary Contact Number*

Alternate Contact

Alternate Contact Phone

Your pet will be undergoing general anesthesia plus a surgical procedure today. There is always some risk involved with general anesthesia including heart or breathing problems, problems with blood pressure, and even the risk of death. The risk of problems under anesthesia may be affected by the health of your pet, your pet’s age, and potential underlying problems. We will take every precaution possible to ensure the safest anesthesia for your pet.

Labwork will be performed on your pet prior to surgery to ensure proper kidney and liver function as well as look for any underlying illnesses. Your pet’s blood pressure, heart rate, respiration, and oxygenation will be monitored throughout surgery to keep us aware of any problems that may develop. We will also administer intravenous fluids throughout surgery to maintain your pet’s hydration and to help maintain your pet’s blood pressure.

If you have any questions regarding your pet’s surgery or anesthesia, please ask before signing below. If you understand the risks involved and wish to go ahead with anesthesia, please sign below.

Signature*

Name

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Anesthesia/Surgery Consent Form

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913-469-9330

913-469-9330

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