Anesthesia Consent Form

Alternate number if someone else is responsible for post-op pick-up/care*

Relationship to alternate

Procedure(s) to be performed today*

We will call you if we find anything not addressed in the signed estimate. However, if you cannot be reached:*

Please continue with the doctor’s recommendations of the highest quality standard for my pet’s health.

Do not continue with any unexpected changes unless I can be reached. I understand that my pet may be recovered from anesthesia without recommended treatment(s) if I cannot be reached when needed.

Pet's Name*

When is the last time your pet ate?*

Has your pet had any vomiting or diarrhea lately?*

Yes

No

Is your pet on any medication?*

Yes

No

Have we reviewed your pet’s pre-operative blood work results?*

Yes

No

Has your pet been under anesthesia before?*

Yes

No

I approve of the recommended post-operative care items if needed:*

Pain medication

E-Collar / Lick Sleeve

Providing confined space for my pet to fully recover safely

Reviewing post-anesthesia expectations & post-operative in-home instructions provided by the doctor

I verify I am the owner (or Authorized agent for the owner) of the above-named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian.

I have been advised of the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in healthy animals, and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures that are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment.

I also accept responsibility for any additional charges accrued related to the additional needs of my pet.

I understand full payment is due at the time my pet is released from the hospital. I also understand I have full responsibility for my pet’s safety once released from the hospital and agree to read any post-anesthesia instructions provided by West Phoenix Veterinary Hospital.*

I have read and accept all the information above

In the rare event a patient experiences cardiac arrest, I (...) like the team to perform CPR on my pet.*

Would

Would not