Anesthesia/ Surgical Consent Form

Client Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email

Pet Patient Name*

First

Species*

Breed

Sex*

Color*

Weight

Age*

Microchip #

Anesthetic and surgical procedure(s) to be performed:

Is your pet on any medications currently, and when was the last dose? *

Additional Surgical Information

All pets dropped off for surgery must be current on vaccinations. If you are unable to provide proof of vaccination, your pet will be updated at your expense.

Please read the following information outlined below and choose YES or NO for EACH choice.

Pre-anesthetic Blood Profile*

YES, please perform the pre-anesthetic blood profile at the cost of $61.00
NO, do not perform the recommended pre-anesthetic blood profile.

Performing bloodwork prior to using anesthesia provides invaluable information about the health and functioning of your pet’s internal organs and how well your pet can metabolize anesthesia. Red and white blood cells provide information regarding oxygen-carrying ability and how well your pet can fight infection. Platelet counts indicate how effectively your pet is able to stop bleeding.

Microchip*

YES, please implant a microchip to permanently identify my pet at the cost of $64.40
NO, I decline the implantation of a microchip.

This identification system will be registered with a national database to identify your pet in the event that it is lost.

Elizabethan Collar*

YES, please fit my pet with an elizabethan collar to protect the surgical site.
NO, I will monitor my pet and be responsible if he/she should damage the surgical site.

Sedatives for Recovery*

YES, I will need medication to reduce my pet's anxiety and activity level during recovery from the procedure.
NO, I will manage my pet's activity level without medications.

Biopsy*

YES, please send the growth out for biopsy for an additional cost of $175 to $220
NO, I do NOT want to send the growth out for biopsy.
I would like for the doctor to decide if the growth should be sent out

To determine what type of growth we removed, and the likelihood of it spreading or returning, sending the growth to the lab for further investigation is often helpful. If you aren't sure whether you should elect to send the growth out for biopsy, leaving it to the doctor's preference may be the best option. Results for biopsy generally take 4-7 days, depending on which day it is received. All bladder stones are sent to the lab for analysis.

DNR*

YES, please utilize every possible life-saving procedure available to allow my pet every opportunity for a full recovery.
NO, I feel that resuscitating my pet at this time would not be in his/her best interest.

In the unlikely event that your pet arrests during the anesthetic procedure listed above, what would your preference be:

Consent & Release*

I agree to the policies outlined in this document

I understand that any time anesthesia is used, a certain amount of risk is involved. I understand there is a pre-anesthetic test (Bloodwork) that may decrease the risks associated with anesthesia. I understand the increased risk of complications as a result of not performing this test before anesthesia. I hereby authorize and direct the veterinarian to perform the procedures and/or additional diagnostic and/or treatment procedures as deemed advisable for my pet. I realize that will perform all procedures and treatments to the very best of their abilities and will use all reasonable precautions to ensure my animal’s health and safety. However, makes no guarantee or warranty regarding the results of treatment or procedure. I will hold harmless (and employees) should my pet injure itself, escape, fail to eat, become ill, or die. I understand that should my pet need extractions during a dental cleaning, those extractions will be performed without contacting me. While it is considered optional, an elizabethan collar (lampshade) is strongly recommended for any pet going home with an incision. If I choose to decline it, Affordable Care Veterinary Clinic is not responsible for any damage my pet does to the incision site. I understand that if my pet is found to have external parasites upon exam, it will be treated at owner’s expense.

Additionally, any pets found to have retained "baby" teeth, they will be extracted at the time of surgery. All pets undergoing anesthesia will receive a complimentary nail trim. I have consented to the above procedures and I agree to pay in full any and all costs incurred involving my pet at the time the services are rendered.

AFFORDABLE CARE VETERINARY CLINIC IS NOT STAFFED FOR 24-HOUR CARE. PETS THAT ARE HOSPITALIZED WILL BE WITHOUT CONSTANT SUPERVISION ONCE THE OFFICE IS CLOSED.

Additional Surgical Information

Shop From Home

Online Pharmacy

Contact Us

Our Location

Contact Us

Our Hours