Owner's Name

Name*

First Last

Contact Number*

The number we can contact you at on the morning of the surgery.

Pet Information

Pet's Name*

Is your pet currently on any medication(s) or supplement(s)?

Yes
No

Medication / Supplement Description:

ANESTHESIA CONSENT

I, hereby authorize Clearwater Animal Hospital to use general anesthesia on my pet named above for the treatment/surgery. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns that I have about those risks with the veterinarian before the procedure is initiated.

Any questions I have regarding the following issues have been answered to my satisfaction.*

The reasonable medical and/or surgical treatment options for my pet.
Sufficient details of the procedures to understand what will be performed.
How fully my pet will recover and how long it will take.
The estimate of the fees for all services.
The length any type of follow up care and home restraint required.
The most common and serious complications.

I am aware that if any additional medications, treatments, or services are required due to complications associated with this procedure, I, the owner am responsible for all fees associated with the additional services provided.*

A new treatment plan will be presented prior to those services being provided. This may also take place as a discussion with you over the phone.

Consent*

I have read and understand Anesthesia Consent.

PRE-ANESTHETIC BLOODWORK CONSENT

By testing your pet before anesthesia, you help reduce his or her risk of anesthetic complication. Pre-anesthetic testing helps understand whether your pets' vital organs are functioning properly and that your pet can properly process and eliminate anesthesia. Just like when people undergo an anesthetic procedure, your doctor would perform pre-anesthetic testing.

If all the tests are normal, it does not guarantee that your pet will not have an anesthetic reaction, but it does tell us that your pet is healthy and in a low-risk category. Any anesthetic carries a serious risk. The more information we have the safer that risk will be.*

If any of these test results are abnormal, the veterinarian will discuss the findings with you and may decide to do one of the following:1. Postpone the procedure 2. Further testing to pursue a specific diagnosis 3. Proceed with anesthesia, but alter the drugs and procedure(s).

I ACCEPT a pre-anesthetic blood chemistry and CBC profile.
I DECLINE a pre-anesthetic blood chemistry and CBC profile.

Consent*

I have read and understand Pre-Anesthetic Bloodwork Consent.

EMERGENCY CONSENT

Please select how to proceed in the event of an emergency:*

I acknowledge and understand that anesthesia poses a risk to my pet, regardless of health status. In the event of unforeseen complications, I GIVE permission to the doctors and staff of Clearwater Animal Hospital to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action.
I acknowledge and understand that anesthesia poses a risk to my pet, regardless of health status. In the event of unforeseen complications, I DO NOT GIVE permission to the doctors and staff to take measures in treating my pet and I understand that my pet may die without immediate critical care. In making this decision, the doctors and staff at Clearwater Animal Hospital will not be held liable or responsible in any manner whatsoever.

Consent*

I have read and understand Emergency Consent.

ESTIMATE CONSENT

Consent*

I am the owner of or am acting as an agent for the owner of the pet named above and accept full financial responsibility. The doctor has explained the medical condition of my pet and the proposed regiment of treatment and/or surgery. I authorize the doctor to proceed as discussed. I understand that a good faith effort was made to make to the above treatment plan totally accurate to within a +/- range of 15%. I can be contacted during the estimated treatment period to be advised and give consent to any unforeseen charges. A deposit of 50% of the estimated treatment cost is required prior to the commencement of any surgery.

Anesthetic Consent Form

Owner's Name

Pet Information

ANESTHESIA CONSENT

PRE-ANESTHETIC BLOODWORK CONSENT

EMERGENCY CONSENT

ESTIMATE CONSENT

CLEARWATER ANIMAL HOSPITAL

LASALLE ANIMAL HOSPITAL

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