Anesthesia/Surgical Authorization Form

Owner's Name

Owner's Email

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Owner's Phone Number

Please provide a number the owner can be reached at during the scheduled surgery time.

Pet Information

Patient's Name

Patient's Breed

Patient's Sex

Patient's Age

Patient's Color/Markings

When was the last time the patient ate?

Is the patient on any Medications? If so, please list the name, the dosage and the last time it was administered.

Please carefully review the following statements. By checking each box, you acknowledge that you have read and understand the statement.

I understand that some risks always exist with sedation, anesthesia and/or surgery, and I have been encouraged to discuss any concerns I may have about those risks with my veterinarian before the procedure(s) is/are initiated. Surgical and anesthetic risks include, but are not limited to, infection at the surgical site, unexpected blood loss, and anesthetic or surgical complications up to and including death.

These complications may include but are not limited to:

Vomiting
Abscess from Suture Reaction
Urinary Tract Infection
Diarrhea
Incisional Infections
Seroma Formation
Dehiscence
Dermatitis

I authorize the use of appropriate anesthetics and other medications, and I understand that the hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedures or operations and understand the risks involved and realize results cannot be guaranteed. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures.

I understand that the attached surgical estimate provided to me during my pre-surgical consultation at East Hills Veterinary Clinic does not include any additional costs that I may occur if any possible complications may arise as a result of this surgical procedure. I also understand that I am solely financially responsible for the continued care and treatment of my pets’ complications if any arise as a result from this surgical procedure.

In an effort to make anesthesia as safe as possible, we employ the following except where the circumstances of the case require a change in the protocol.

A complete physical exam.
Appropriate pre-anesthesia medications provide for analgesia and relaxation so your pet can go under anesthesia and awaken from it more smoothly, as well as provide adequate postoperative pain control.
Monitoring of vitals during anesthesia and recovery.

I understand it is recommended that the pre-anesthetic CBC and Chem bloodwork be completed less than 30 days prior to surgery.

Pre-anesthetic blood work has been completed.

I authorize this bloodwork to be performed.

I have declined the recommended profile

I understand this does not give the attending veterinarian a complete profile of internal organ function, and that there may be an underlying disease which could cause greater risk regarding sedation/anesthesia and recovery.

I understand East Hills Veterinary Clinic is not a 24-hour facility and does not have personnel after business hours. I have been given the option to transport my pet to a 24-hour facility such as VET, MedVet, or CARE Center at my own expense for overnight monitoring.

Authorization

Procedure Being Performed

I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give CINCINNATI FAMILY VET DVMs, their agents, servants, and/or representatives full and complete authority to perform the anesthetic/surgical procedure described and to perform any other procedure that, at their discretion, may be useful to promote the health of the above described pet, and I do hereby and by the presents forever release the said doctor, their agents, servants, or representatives from any and all liability arising from said surgery on said animal.

I understand that the attending veterinarian will make every effort to contact me regarding treatment in case of unforeseen emergencies.

In the event of an emergency, I select the following resuscitation option:

I give permission for life-sustaining procedures, CPR (Cardio Pulmonary Resuscitation).

I do not give permission for life sustaining procedures, DNR (Do Not Resuscitate)

By signing this consent form, I indicate that I have authorized the described procedures and that any questions I may have were answered to my satisfaction.

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Anesthesia/Surgical Authorization Form

Pet Information

Authorization

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