Pet Information

Pet's Name *

Contact Information

Owner's Name *

First

Last

Email *

Phone Number to Reach You Today *

Secondary Contact's Name *

First

Last

Secondary Contact's Phone Number *

This person has the authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

Surgical Procedures

Preparation: We follow sterile procedures. We use surgical preparations, surgical packs, and surgical attire. The skin around the surgical area will be clipped and scrubbed with an antiseptic. *

I have read and understand.

Anesthesia: We will conduct a pre-surgical physical exam and conduct 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, respiration rate and quality, blood pressure, oxygenation, and depth of anesthesia during the procedure. *

I have read and understand.

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

I have read and understand.

Catheterization: For most surgical procedures, we will place and intravenous catheter to provide us with an easy route to administer medications and fluids during the procedure. This will allow us to support kidney function and blood pressure, if necessary. (copy) *

I have read and understand.

Pain Management: We pro-actively 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.

In an effort to maintain patient safety and hospital cleanliness, your pet will be given a 24 hour flea pill if any fleas or flea dirt are noted upon physical examination. *

I have read and understand.

Today's Scheduled Surgery

Today's procedure is: *

(example: neuter, dental cleaning, etc.)

Additional Services Desired While Patient Is Sedated

I DO wish to include Pre-anesthetic bloodwork before my pet's surgery today. (CBC and Comprehensive Chemistry Panel) (~$130.00)

Yes
No

Please Note: This is required for patients 7 years and older.

Additional services requested (Please select all that apply)

Implant Microchip ($74.42)
Nail Trim ($12.77)
Clean Ears ($15.05)
Express Anal Glans ($16.30)
Sanitary Clip (rectum, genitals) ($17.43)
Remove Lumps (specify location of lumps below) (Price VARIES)
Other (specify below)

Please specify the location of your pet's lumps that you wish to be removed.

Please specify.

Authorization

Payment is due when services are rendered. *

I have read and understand.

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 encourage to dicuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any questions have been answered to my satisfaction. *

I have read, understand, and authorize.

I authorize Midtown Veterinary Hospital to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. I understand there are rare complications associated with any anesthetic or surgical procedure. 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 and understand the veterinarians and hospital staff will try to minimize these risks. I will not hold Midtown Veterinary Hospital, the veterinarians, or any staff member liable for any complications that may arise. *

I authorize resuscitation efforts for my pet.
I DO NOT authorize resuscitation effort for my pet.

I HAVE READ AND UNDERSTAND THIS ANESTHESIA FORM. *

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

Signature of Responsible Party *

Date *