Canine Pre-Anesthesia Consent Form Client/Patient InformationClient's NamePatient's NameYour E-mail AddressPrimary Contact NumberBy signing this form, you authorize the doctor to treat your pet as necessary should he/she be unable to contact you at the number(s) provided above.Procedure to be performed todayChecklistHas patient had any food since 10:00 pm? Yes NoDoes the patient have any history of seizures? Yes NoDoes patient have any history of adverse drug reactions? Yes NoIf YES, please list drug name(s):Was your pet given any medication within the last 24 hours? Yes NoIf YES, when, what type, and how much?Patient is: Male FemaleFemale patients to have spay: Has patient been in heat within the last 4 weeks? Yes NoPre-Anesthetic Blood Work Bloodwork is performed to evaluate your dog’s health prior to anesthesia. The results of bloodwork screening can warn us about underlying conditions that could lead to possible complications. We are especially concerned with the condition of the liver and kidneys as these are the primary organs that metabolize anesthetic drugs. Listed below is a description of bloodwork we offer. Please check the level of screening you would like for your pet. If your pet is 8 years of age or older, we highly recommend a senior blood panel. Please select bloodwork(s) to be done: Chem 10 & PCV:Checks kidney & liver function, blood glucose, proteins in blood, and packed-cell volume. REQUIRED CBC:Evaluates white and red blood cell and platelet counts, which are an indication for blood clotting, oxygen carrying capacity, and inflammation. OPTIONAL with Chem 10 Senior Panel: CBC + Blood Chem 17HIGHLY RECOMMENDED for animals 8 years of age and older. Full Panel: CBC + Blood Chem 17 + Electrolytes, T4 (thyroid), and SDMAGives the most information on the health of your pet.Microchipping We offer microchipping for your pet. This is a small chip that is implanted under your pet’s skin on the back of the neck that is used for identifying your pet may he/she get lost. We suggest that it is implanted while the pet is under anesthesia. This offer may or may not be included in the estimate provided. Please check one of the following: I AGREE to have my pet microchipped today. I DECLINE to have my pet microchipped today.Dental Procedures For patients scheduled for dental cleanings: a dental cleaning for dogs and cats involves a full mouth health examination, cleaning, and, if necessary, extraction of teeth. When a pet’s teeth are loose or abscessed, it is left to the veterinarian’s discretion as to whether or not they should be extracted. Cost is based on the length of time required to extract the teeth. Please speak directly with your pet’s veterinarian to determine approximate cost of extractions if not already provided on the estimate. Please check one of the following in case any unexpected extractions are found: Yes, I give permission for the veterinarian to extract any teeth necessary. No, I want to be contacted before the veterinarian extracts any teeth.Recovery Option Your pet will need to remain calm and quiet throughout his or her recovery process (about 7 to 10 days). Would you prefer to have medication at home that will help keep your pet calm? Yes, please fill medication for my pet. No, my pet will not need medication.Does your pet need to be updated on any vaccinations or other services while here?If so, please select from the following: DHLPP/C Nail Trim Heartworm Test Bordetella Fecal Heartworm Prevention Rabies Anal Glands Flea Prevention Lyme Clean EarsAdvance Directive for Resuscitation To provide the safest anesthesia for your pet, we perform a thorough pre-surgical examination and pre-anesthetic bloodwork. During anesthesia your pet is being monitored by trained veterinary staff. Despite all of the precautions we take, anesthesia is never completely without risk. For this reason, we ask all clients about their wishes regarding CPR. Our hospital mission is to provide the best care for your pet and to update you regarding any changes in the condition of your hospitalized pet. In the event of a life threatening situation, we will contact you immediately. Please advise us whether you would wish CPR (cardiopulmonary resuscitation) to be performed on your pet: Yes, please perform CPR in the event that it becomes necessary for my pet. No, please do not perform lifesaving measures. Do Not Resuscitate.SPECIAL NOTES, PLEASE READ: PARASITES If parasites are found on your pet while hospitalized, we will treat the pet with the necessary treatment at the owner's expense for the protection of your pet and that of others in the hospital. VACCINATIONS All pets over six months of age are required to be vaccinated for rabies according to state law. If your pet has not had a rabies vaccine prior to his/her visit, or if proper documentation cannot be provided, the pet must be vaccinated for rabies.I have read and understand the above information.Signature of owner or agent Sign Here Submit Form
