Anesthesia Consent Form

Anesthesia Consent Form
What procedure is your pet having done?
Did your pet eat this morning?
Age and Health Status:
Young(<7 years) and healthy
Would you like your pet to have Pre-Anesthetic labwork?
Mature(>7years) OR Pre-existing Conditions

Our greatest concern is the well-being of your pet. Therefore, we highly recommend that your pet receive pre-anesthetic blood testing. This testing will allow us to evaluate the kidneys and liver these organs are important for anesthetic safety. We also evaluate other parameters, including a CBC and electrolytes. If an abnormality exists, you will be contacted before we proceed, to ensure the safety of your pet. In some cases, the procedure may require postponement and/or cancellation due to safety.

An IV catheter will be placed, and fluids given to every anesthetized pet. An IV catheter is our first line of defense in the event of an anesthetic emergency. It allows direct access to the blood stream to administer emergency medications. IV fluids also aid in the maintenance of hydration as well as managing blood pressure. Fluids also help us to “flush” the system of remaining anesthetic drugs.

Has your pet experieced any of the following? symptoms
Would you like any additional services for your pet while here?
Is your pet up to date on vaccines?
Note* Rabies and DHLPP vaccines are required for dogs. Rabies and FVRCP vaccines are required for cats.
If not, what vaccines would you like your pet to receive while they are here?
Is your pet on any medications?
Is your pet on a special diet EXCLUSIVELY, as in, that diet is the only diet he/she is allowed to eat?
Dental Cleaning Options
If your pet is having his/her teeth cleaned today and/or extractions performed, please answer the 2 questions below.
Dental X-Rays:

Sanos is applied after the professional dental cleaning to protect under the gumline and the ‘difficult to reach’ areas such as under the gums of the back (caudal) teeth. Sanos is a gingival dental sealant for dogs and cats that seals the subgingival gum line (gingival sulcus) against the formation of plaque. Clinically proven and VOHC certified to last for 6 months without any take-home application required.

Sanos Dental Sealant

It is extremely important that we can reach you today for surgery updates including post-operative communication & MORE IMPORTANTLY, QUESTIONS THAT MAY ARISE WHEN YOUR PET IS UNDER ANESTHESIA.  If the doctor has a question during your pet's procedure and he/she cannot get ahold of you, the doctor will use his/her best judgement regarding your pet.  For instance, if your pet has a broken tooth and the doctor calls the number provided to discuss extracting the tooth, and nobody answers, the doctor will proceed with making what he/she feels is the best decision.

In Case of Emergency:
Consent for Procedure

As the owner or representative of the owner, I authorize the surgery/anesthetic procedures outlined in my estimate & that payment in full is due when picking up my pet.  If my pet is having a non-elective procedure, I understand that an estimate will be provided & that a deposit in the amount of 50% is due before anesthesia can be performed. Current forms of payment include Visa, Mastercard, Discover, American Express, debit, and Care Credit. 


I understand that I will assume full responsibility for the care of my animal after it is released from the hospital, and that I should and will contact the hospital immediately if questions or complications develop during home care.

I do hereby acknowledge that there are no guarantees either implied or expressed that the procedures authorized will be without complications from unexpected events beyond the veterinarians’ and hospital’s control.  If my pet is found to have fleas, my pet will be treated and I will incur this additional expense.  Lastly, for my pet’s safety, I understand that all cats need to leave the hospital in a carrier (one can be borrowed or purchased here) & all dogs need to leave on a leash (one can be borrowed).

Thanks for submitting!