Pet Name *

Owner Name *

First

Last

Email *

Number to Reach you Today *

*It is important to list a number where you are most accessible*

Additional Contact Name and Number *

*This person must have authorization over medical decisions in the event we cannot reach you*

Today’s Procedure

Surgical Procedure Protocol

Preparation: We follow sterile procedures. We use surgical preparation, surgical packs, and surgical attire. The skin around the surgical area will be shaved and scrubbed using aseptic technique. *

I have read and understand.

Anesthesia: We will conduct a pre-surgical physical exam and may conduct a blood analysis to assess and minimize the risk of anesthesia for your pet. *

I have read and understand.

Monitoring: We further minimize anesthetic risk by monitoring heart rate and rhythm (EKG), respiration rate and quality, CO2 concentration, blood pressure, oxygenation, temperature, reflexes, and depth of anesthesia during the procedure. *

I have read and understand.

Catheterization: For surgical procedures, we will shave the area where the intravenous catheter will be placed to provide us with an easy route to administer medications and fluids during the procedure. This will allow us to support kidney function, blood pressure, and provide emergency medications if necessary. *

I have read and understand.

Pain Management: We proactively manage pain associated with any procedure with appropriate pain management medications. As with any drug, side effects may be associated with their administration. *

I have read and understand.

After care of your pet

We will give you a call once they are recovering and a good time frame when to come pick up your pet. We will also email you detailed discharge instructions regarding after care for your pet.

We like to give them a snack* (Gastrointestinal Low Fat: Chicken based highly digestible and gentle on digestion) once they are able to walk without assistance to break fasting and have them go outside for a restroom break. *

Yes, I am ok with giving a snack to break fasting
No, Thank you as my pet has food allergies/sensitivities

Is your pet currently on any medications? If yes, please notate the medication, strength, dosage, last time they received it and route of administration below:

Pre-Anesthetic Blood Work:

Although bloodwork is recommended, it is not required by our doctors unless they are 7 years of age or older. If your pet falls in this age range we would not have to do labs if they were done within 4 months. Tests exceeding 4 months prior to anesthesia will need to be repeated. This information helps us determine whether we need to take additional precautions or postpone the procedure. *

Yes, I would like pre-anesthetic blood work done today/I am required to do blood work
No, I do not want pre-anesthetic blood work done and understand the risks

Behavioral Information

Does your pet have any sensitive areas that they do not like to be touched by others?

How would you describe your pet around other people/animals?

Please Confirm *

I have NOT given my pet any food after 8 PM on the night before the procedure, unless otherwise advised by my doctor. I understand this is important for anesthesia safety.

Authorization for CPR

In the event of a medical emergency I authorize Midtown Veterinary Hospital to perform any additional diagnostic treatment or surgical procedures deemed necessary for any unforeseen circumstances. I understand there are rare complications associated with any procedures. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks, understand that there are inherent risks to CPR, and hold the veterinarians and staff members harmless from liability to complications that may arise. *

I DO authorize CPR
I DO NOT authorize CPR

I authorize anesthesia/surgery for my pet. The nature and risks of this procedure have been explained to me. I understand some risks always exist with anesthesia and/or surgery, and I am encouraged to discuss any concerns. I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that all information given is true and that any questions have been answered to my satisfaction.

Signature *

Clear Signature

Date *

Anesthesia Consent Form

Surgical Procedure Protocol

After care of your pet

Pre-Anesthetic Blood Work:

Behavioral Information

Authorization for CPR