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Pre-Anesthesia Consent Form

Client/Patient Info

Owner's Name (*)

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Email (*)

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Date (mm/dd/yyyy) (*)

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Pet's Name (*)

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Species (*)

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Client Number

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Breed (*)

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Color

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Age

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Consent Info

Like you, our greatest concern is the well being of your pet. Prior to administering anesthesia to your pet, a full physical exam is performed. Included in the price of each procedure is: (1) an intravenous catheter and fluid therapy, (2) pain medication before, during, and after the procedure, (3) state of the art anesthesia monitoring.

Pre Anesthetic Blood Testing (*)
A blood analysis can reveal underlying problems that may not be outwardly visible. This test provides us with a look at your pet’s vital organ function which can play a critical role in determining how much risk is involved. Before administering any anesthetic, a doctor will evaluate these test results. ($60)
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Additional Pain Medication (*)
I request an injection of Buprenex (an opioid) during surgery and Carprofen (an anti-inflammatory) to take home to aid in pain relief and healing ($45-60)
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Microchipping (*)
30-40% of all pets will get lost in their lifetime. We recommend all pets be permanently identified through the use of a microchip implanted under the skin. This quick and simple procedure gives your pet permanent identification that will assist in the return of your pet if found and scanned by and animal shelter or veterinary hospital. ($50, includes registration through HomeAgain)
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Primary Contact Number (*)

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Alternate Contact Number (*)

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I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and have the authority to execute this consent.

I understand that during the performance of the procedure, an unforeseen situation may arise that necessitates an extension or variance in the procedure set above. I hereby authorize South Buffalo Springs Animal Hospital to use reasonable care and judgment in performing the procedure.

I have been advised as to the nature of the procedures and the risks involved in performing general anesthesia to the above described animal. I realize that results cannot be guaranteed.

I have read and understand this authorization and consent. I further understand that I assume financial responsibility for all services rendered.

By pressing the submit button, I, the owner of the above pet, agree to all of the above statements.