Surgery/Anesthesia Consent Form

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Pet Name

Species

If Other, please specify

Breed

Date of Birth

Age

Sex

Your pet will be undergoing general anesthesia plus a surgical procedure today. Please review the consent and do not hesitate to inform us of any questions or concerns you may have.

Pre Anesthetic Blood Work

In order to recognize any underlying abnormalities your pet may have, we recommend having a pre-surgical profile run on your animal. Pre-anesthetic blood work checks the internal organs and blood count and is a vital part of safe anesthesia. Help us provide the best level of care for your pet by choosing to perform blood work prior to anesthesia or sedation. Please note, some procedures REQUIRE bloodwork. The staff at AVMC will review this with you when applicable.

Authorization and Risk Assessment

Please initial after each statement below

I understand that unforeseen conditions may be revealed during the procedures that may require more extensive or different treatments. I understand that all reasonable efforts will be made to contact me to authorize any additional treatments. However, if these efforts are unsuccessful, I authorize the performance of any procedures or treatments that are deemed immediately necessary for the health and wellbeing of my pet in the professional opinion of the attending veterinarian.

I understand that I assume financial responsibility for all services rendered.

The veterinarian has described the procedures to be performed and has explained to my satisfaction the purpose for performing them and the risks involved with them. I realize that there can be no guarantee as to the outcome of any procedures.

I hereby authorize anesthesia/surgery for my pet. I understand that some risks always exist with anesthesia and/or surgery. My signature on this consent form indicates that any questions have been answered to my satisfaction. While Valley Oak Veterinary Clinic provides the highest quality of anesthesia monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical procedure. In particular, I have been advised that there is an extremely small risk of death, complications, or side effects (which can present themselves well after the procedure) every time an anesthetic is used and that I have been advised of the possibility. I acknowledge these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I will not hold Valley Oak Veterinary Clinic, the veterinarians, or any staff member liable for any complications that may arise.

Consent for CPR or DNR

In the case that your pet were to suffer cardiac and/or pulmonary arrest (heart or breathing stops), do you authorize us to provide Life-saving measures (i.e. cardiopulmonary resuscitation)? Costs of these services can be $500 and are NOT reflected in this estimate. If you choose to allow these procedures for your pet, you will be contacted as soon as possible to be informed of the situation and given the options how to proceed.

Emergency Contact Phone

Date

I have read and understand this authorization.

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