Surgery/Anesthesia Consent Form

Client Name(Required)

First Last

Pet's Name(Required)

Owner/Authorized Agent

As Owner/Authorized Agent of the above named animal, I hereby authorize Petsadena Animal Hospital to perform the following under general anesthesia:

Procedure(s)

In case of an emergency and/or prior to additional procedures, you will be contacted by telephone.

The phone number(s) where you can be reached TODAY is

Phone 1(Required)

Phone 2

Surgical/Anesthesia Information:

All pets undergoing anesthesia at Petsadena Animal Hospital are required to have pre-anesthetic blood testing to look at basic organ function and to tailor anesthetic medications used. This will also check for pre-existing medical conditions, which may increase the risk of complications during surgery
An intravenous catheter will be placed to provide immediate access to your pet’s circulatory system, this allows for rapid administration of drugs should an emergency situation arise. Your pet will also be administered intravenous fluids to help maintain normal blood pressure, protect vital organs, and maintain proper hydration.
All pets undergoing surgery will receive pain injections while in the clinic. Post-operative pain management is a concern with virtually all surgical procedures. Most procedures merit at-home oral medication for several days after surgery and will be dispensed at the veterinarian's discretion.

Additional elective procedures offered (please check services that you would like performed)

Nail Trim ($15.13)

Ear Cleaning ($62.47 - $103.01)

Microchip Implantation ($83.59)

Anal Gland Expression ($40.03)

Authorization and Risk Assessment:(Required)

The nature of the procedure and the potential risks have been explained to me and I understand the procedure(s) to be performed. I understand that some risks always exist with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any and all my questions have been answered to my satisfaction.

I understand that during these procedures great care is taken to ensure my pet’s health, but unforeseeable conditions may occur that necessitate an extension or variance in the procedure(s) defined above. I authorize Petsadena Animal Hospital to perform any additional diagnostic, treatment or surgical procedure(s) deemed necessary for medical or surgical complications or any unforeseeable circumstances. I accept responsibility for any result in additional charges.

While Petsadena Animal Hospital provides the highest quality of anesthesia monitoring and surgical services, I understand the risks and understand that the veterinarians and hospital team will do everything possible to minimize any risks. In the event of a life-threatening emergency, I authorize the attending doctor and the team of Petsadena Animal Hospital to perform procedures deemed medically necessary. I will not hold Petsadena Animal Hospital, the veterinarians or any team member liable for any complications that may arise. No warranty or guarantee has been stated or implied to me as to the results or cure afforded by these treatments or procedures.

I understand that I am assuming full financial responsibility for all services rendered at the time my pet is discharged from the hospital.

Must check all boxes

GENERAL INFORMATION ON CARDIOPULMONARY RESUSCITATION (CPR):(Required)

I acknowledge that anesthesia carries some risks, including the potential need for cardiopulmonary resuscitation (CPR) in the event of a cardiac or respiratory arrest. CPR includes chest compression, intubation and manual oxygenation, and emergency injectable drugs. Less than 5% of animals that require CPR will survive to be discharged from the hospital. Despite the best efforts of the veterinarians and staff at Petsadena Animal Hospital, CPR may not save your pet's life. Even if CPR is successful in restoring your pet's life, your pet may not regain his/her normal mental and physical health.

Please initial the option that you wish below:(Required)

APPROVE CPR

DECLINE CPR - DO NOT RESUSCITATE (DNR)

Signature(Required)

(Your digital signature (full name) is as legally binding as a physical signature.)

Date

The phone number(s) where you can be reached TODAY is

Surgical/Anesthesia Information:

Contact Info

Office Hours