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Anesthesia Consent Form

Client First Name(Required)

Client Last Name(Required)

Address(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Phone Number(Required)

Pet's Name(Required)

I have been informed of the risk and potential complications of the procedures.

I have been given no guarantee of the success of the procedures or treatment.
I understand that the hospital will provide an estimate for the routine procedure. I understand that this is only an estimate and due to the nature of the practice of medicine, unforeseen events, complications, or medication that may have to be sent home, this may increase fees beyond the estimate.

If my pet is not coming in for a routine procedure listed below, I have been given an estimate for that procedure. *(client initials)(Required)

Client Initials

I agree to pay the fees in full at the time of the animal’s release from the clinic. *(client initials)(Required)

Client Initials

I would like my pet to have the following additional procedures while sedated:

Microchip(Required)

Yes

No

Nail Trim(Required)

Yes

No

Routine Ear Cleaning(Required)

Yes

No

Anal Gland Expression(Required)

Yes

No

By signing this agreement, I am agreeing to all the above and I have the authority to authorize consent for the above-named animal to be placed under anesthesia and have the following procedure done.

If I have someone else bring in my pet for their procedure check in appointment, I give the following person permission to make decisions on my behalf.

First Name

Last Name

Signature(Required)

Date(Required)

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