Oliver Animal Hospital
Anesthesia/Surgical Consent Form
I, ______________________________, hereby authorize Dr. _____________to perform
First name Last name
the following procedures: __________________________ upon__________________
Should an emergency arise requiring procedures in addition to or different from those now contemplated, I further request and authorize her/him to do whatever she/he deems advisable. I consent to the administration and use of anesthesia. I agree to pay in full for all the services rendered, including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. The nature and purpose of the procedures, possible alternative methods of treatment, risks involved, and possibility of complications, including death, have been fully explained to me. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.
We require placement of an IV catheter to administer fluids while under anesthesia. IV fluids will aide the body in stabilizing internal organs and blood pressure, and aid in metabolizing the anesthesia more efficiently. Along with shaving the hair at the IV catheter site, we may also shave other areas including the surgical site for surgical prepping and cleansing and also the monitor sites so they will function properly.
Your pet will be administered pain management drugs. Pain management drugs will allow your pet to have a more comfortable and faster recovery. We believe controlling our patient's pain is important. For that reason we will administer medication before, during and after your pet's medical procedure to control pain, reduce discomfort, and promote recovery.
All patients admitted for surgery must have a pre-operative blood panel to screen for pre-existing internal conditions that may not be evident physically, but could possibly lead to complications. There is an additional charge of $40.00 for the pre-operative blood panel.
ALL patients must have preoperative blood work. ___________
We offer Home Again Microchip Identification System. This procedure involves a small microchip implanted just underneath the skin in between the shoulder blades. With this service we also mail in your pet's registration. The cost for the microchip and mailed in registration is $40.00. Initial your choice.
YES, I agree to the microchip ______________
NO, I decline the microchip _______________
If your pet is having a DENTAL PROCEDURE performed, PLEASE READ AND INITIAL YOUR CHOICES.
Factors that limit our ability to detect every dental problem your pet may have with just an oral exam many include: lack of patient cooperation which can impair visualization (especially back teeth), many periodontal problems can only be detected by probing under the gum with an instrument; dental tartar can hide underlying cavities or fractures.
If further problems are detected while my pet is under anesthesia (initial ALL that apply)
__________ Do whatever is needed to give my pet a healthy oral cavity including, but not limited to tooth extractions.
__________ Do only what I have authorized.
__________ Please contact me before doing any additional procedures. If I can not be reached while my pet is under anesthesia then:
______________ Perform what ever procedures are needed.
______________ Do only what I have authorized.
Signature: _______________________________________________Date: ____________________
Phone numbers where we can reach you today: _________________________________