Anesthesia/Surgical Consent Form

Today's Procedure:

Date: *

Owner’s Name: *

Patient’s Name: *

Weight: *

Below are services recommended by HVS to improve upon anesthesia safety and provide comfort following today’s procedure. The HVS staff is pleased to answer any questions you may have regarding these recommendations.

Medical History

Does your pet have any medical conditions, history of complications from anesthesia or known allergies? *YesNo

If so, please describe and discuss with your DVM:

List all medications your pet is currently taking (including supplements) and the date/time of the last dose: *

Has your pet been fasted (no food) since midnight? *YesNo

Pre-Anesthetic Blood Test

In an effort to help minimize anesthetic risks HVS recommends pre-anesthetic blood testing for all pets, especially those seven years of age and older. A CBC/Chemistry panel can provide us with vital information regarding organ function and overall health.

Yes, I authorize pre-anesthetic blood work at $99.00No, I decline pre-anesthetic blood work and accept all associated risks

Intravenous Catheter and Fluids

An intravenous (IV) catheter and fluids allows timely administration of medications and continuous fluid therapy during your pets’ procedure as well as help maintain blood pressure, preserve kidney function, prevent dehydration and facilitate faster clearance of the anesthetics from their system.

Yes, I authorize IV catheter/fluids at $75.00No, I decline IV catheter and fluids and accept all associated risks

Post-Operative Pain Control

Pain medications are recommended to provide a more comfortable recovery, faster healing times and reduced risk of complications. This regiment includes a pre-operative injection as well as dispensed medications to be given at home.

Yes, I would like the recommended pain control $25.00-$45.00No, I decline the recommended pain management

Additional Services

Additional concerns may arise during a procedure which would require immediate attention to stabilize your pets’ condition and every attempt will be made to contact you should this need arise.

If the DVM is unable to reach you: *The doctor is authorized to perform these services at their discretion. Additional fees do applyThe doctor is not authorized to perform these services.

Preventative Medicine

Please select any additional services you are interested in HVS providing for your pet today. Additional fees do apply.

PLEASE ASK FOR A REVISED ESTIMATE IF ANY ADDITIONAL SERVICES HAVE BEEN REQUESTED TODAY

ANESTHESIA-SURGICAL RELEASE I understand the nature of the procedures/surgeries and the risks involved. I realize the results cannot be guaranteed. I hereby authorize the use of such anesthetics as the veterinarian deems advisable and performance of such surgical or therapeutic procedures as the veterinarian determines to be indicated. I am the owner or agent of the above animal and have been given the authority to execute this consent. I hereby authorize the veterinarian on duty to induce and maintain general anesthesia and to perform needed and/or requested surgical or medical procedures for my pet. I have been informed of the possible risks and complications associated from these procedures. I understand there will not be personnel on the veterinary medical premises on a 24-hour observation with my animal. *I have read/understand this authorization form and give consent

Best Contact Number for today: *

Emergency Phone: *

Email Address *

Signature of owner/responsible party: *

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