Gwinnett Animal Clinic, PC Anesthesia Standard Consent Form
Owner’s Name: ______Name of Pet:______
Species: ______Breed:______Sex: ______Age:______
I am the owner or agent for the owner of the animal described above and I have the authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s) or operation(s):
I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions or problems may become evident that necessitate an extension of the foregoing procedure(s) or operation(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary in the exercise of the veterinarian’s professional judgement. I also authorize the use of appropriate anesthetics and other medications and I understand that hospital personnel will be employed as deemed appropriate by the veterinarian. I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I realize that results cannot be guaranteed.
______Food has been withheld since 9:00 PM last night and water has been withheld since 7:00 AM today.
______I understand that your pet may have his/her leg(s) shaved so that a catheter can be set so that fluids may be given during the anesthetic procedure. This keeps the blood pressure up and blood flowing to the vital organs, replenishes fluids, and also provides an injection port for emergency drugs should they be needed.
______For the safety of all our pets as well as our personnel, all pets must be current on rabies vaccinations and dogs must be up to date on Bordatella (“kennel cough”) vaccinations. If they are not, these will be administered while they are hospitalized.
To your knowledge, has your pet ever had any seizures or convulsions? (circle one) YES NO
Other than heartworm and/or flea preventative, is your pet currently on any medication? (circle one) YES NO
Pre-Anesthetic Blood Testing Consent
Our greatest concern is the well being of your pet. A pre-anesthetic blood profile is needed to maximize the patient safety and alert the doctor to the presence of dehydration, anemia, infection, diabetes and/or kidney or liver disease that could complicate the procedure. The conditions may not be detected without a pre-anesthetic profile. In addition, the results of these tests may be useful if your pet’s health changes, serving as a baseline for comparison for future blood tests. The cost of the pre-anesthetic blood chemistry profile and complete blood count is $70.00.
______I accept the pre-anesthetic blood work recommended by veterinarian.
______I decline the recommended pre-anesthetic blood work and request that you proceed with anesthesia. I understand that there are always risks when using anesthesia or performing surgery on an animal.
Signature of Owner/Agent______Date______
Phone number(s) where you can reached today in case of emergency:______
anesthesiaconsentws.doc (7/09)