Anesthesia - Consent Form

Pet History

Please tells us about your pet. Check the box next to each item that is true.

 Was your pet last vaccinated at our hospital? If not, tell us in the Message field below.
 Has your pet ever had any seizures? 
 Has your pet had any vomiting, coughing, or diarrhea in the last 7 days?
 Has your pet had ANY illness or injury in the last 7 days?
 Is your pet allergic to any drugs?
 Did your pet eat this morning?
 Has your pet urinated/defecated this morning?
 Is your pet currently on heartworm medication?
 Is your pet currently on ANY medication? If yes, please note what medications and when were the last doses in the Message field

PRE-ANESTHETIC LABWORK

Whenever an animal undergoes anesthesia and/or surgery, some risk is involved. The amount of risk depends on many factors, including age, physical condition and condition of organ systems (i.e. heart, kidneys, liver, etc.). Anesthetic risks can be greatly reduced with prior knowledge of existing problems. Therefore, it is our policy that all pets undergoing anesthesia be evaluated with a physical exam and labwork prior to anesthesia.

ELECTIVE PROCEDURES

Please ask our staff for the cost of these additional services:

 Microchip Identification: The microchip is a permanent means of identification for your pet. A microchip approximately the size of a grain of rice can be injected under the skin of your pet. If your pet is ever lost, stolen, or injured, a scanner will be able to detect your pet’s ID number and you will be contacted.

 Ear Cleaning: Sometimes the simplest ear cleaning can be difficult, so let us clean the ears while your pet is under anesthesia.

 Nail Trims: Routine anesthetic procedures are an ideal time for nails to be trimmed.

Consent

 I understand that general anesthesia and/or surgery carry with them inherent risks, including infection, cardiac arrest, and death. I authorize the use of appropriate anesthetics and other medications to be used, as the veterinarian deems necessary during the procedure. I understand that some risk always exists with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending doctor before the procedure. In the event that complications arise, I do not hold Dogwood Veterinary Hospital & Pet Resort, its staff, doctors, or agents, liable or responsible. I realize that results cannot be guaranteed, and payment of service is due at the time they are performed. All charges including vaccines and surgery costs shall be paid in full when my pet is released from the hospital. I am the owner or agent of the above-described animal and have the authority to execute this consent. I hereby consent and authorize the performance of the above procedure(s) or operation(s). AFTER CAREFULLY READING THE ABOVE, I HAVE SIGNED IN AGREEMENT.

Please initial here:

Signature will be required upon check-in