Anesthesia/Surgical Consent Form

Client Name *

First

Last

Patient Name *

Phone number at which owner can be reached in case of emergency: *

Email *

Before Procedure:

Before your pet has surgery, they will be examined for any problems that could interfere with the anesthesia. They will be monitored during and after surgery to help ensure a safe recovery.

For our mature patients (7 years & older) or any pets with chronic health problems, bloodwork will be completed prior to anesthesia and/or surgery. This testing will check your pet’s liver & kidney function as well as electrolyte, protein & glucose levels. Occasionally we postpone surgery until a medical problem is resolved. Alternatively, the anesthesia protocol may be changed to accommodate the pet’s medical needs. **The cost of this testing is $76.80** *

Yes, perform pre-anesthesic bloodwork on my pet.
No, I decline bloodwork.
N/A (pet UNDER 7 years)

Even for our healthy, younger patients, pre-anesthetic blood testing, though not critical, can help put your mind at ease by seeing that all is well. On very rare occasions, problems are detected that change our plans. *The cost of testing for young patients is $52.00.** *

Yes, perform pre-anesthesic bloodwork on my pet.
No, I decline bloodwork.
N/A (pet OVER 7 years)

After procedure:

Would you like us to text you after the procedure, or would you prefer a call? *

Text
Call

If text, what number would you like to be texted at?

Our newly acquired surgical laser allows us to do many surgeries with less bleeding and less pain because blood vessels & nerves are sealed as it “cuts”. Your pet may have surgery done with the laser by accepting below. **Additional charge is $42.00.** *

Yes, perform surgery with laser.
No, I decline laser surgery.

Date of last dose of veterinary approved flea/tick medication and brand used:

If fleas are found on your pet, treatment will be done at your expense. We strongly recommend year-round flea prevention.

Anesthetic and surgical procedure(s) to be performed: *

Any other concerns/allergies/procedures?

I, the undersigned owner or agent of the pet identified above, authorize the staff of Osceola Veterinary Clinic to perform the above procedure(s). *

I have read and agree.

I understand that some risks always exist with anesthesia and/ or surgery. I know that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. *

I have read and agree.

I am over 18 years of age and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures. *

I give my permission [yes].
I do not give my permission [no].

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow-up radiographs, re-check physical exams, and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree.

Date *

Anesthesia/Surgical Consent Form

Before Procedure:

After procedure:

Your preferred Osceola veterinary hospital.

Contact

Hours

Location

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