Anesthesia
Consent Form

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Anesthesia Consent Form

We prioritize your pet’s well-being and safety during procedures. This consent form acknowledges your understanding of the anesthesia risks. It authorizes our expert veterinary team to administer anesthesia as required for your pet’s treatment.

Pet Information

Pet's Name *

Contact Information

Owner's Name *

First

Last

Email *

Phone *

Additional Phone

Secondary Contact: *

First

Last

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

Secondary Contact Phone *

Today's procedure is: (example: lump removal, exam, etc.) *

Is your pet currently on medication?

Did your pet receive these medications today?

Please list medication, frequency and dosages if any

When did your pet last receive food? Water?

Pre-Anesthetic Blood Work Release

Your pet is scheduled for an anesthetic procedure. We recommend a comprehensive blood analysis to determine your pet's anesthetic risk criteria. In addition, these results may serve as a baseline for future comparison and evaluation. **If your pet is here through Blue Chip Farm Animal Rescue, these tests ARE NOT paid for by them.

Pre-Anesthetic Blood Work Release

I-Stat (basic kidney, electrolytes, anemia)
Limited Chemistry (basic kidney, liver and organ function, assists in detection of inflammation, infection, anemia, dehydration etc.
CBC + Extensive Comprehensive Chemistry (kidney function, liver function, electrolytes, assists in detection of inflammation, infection, anemia, dehydration etc.)
I decline the recommended pre-anesthetic blood work at this time and request that you proceed with the anesthesia, although anesthesia risk for my pet has not been determined. I assume full responsibility for this animal.
Recommended pre-anesthetic blood work was performed at a previous appointment within the last 6 months. This blood work was either performed at Creekside Animal Hospital, or a complete copy of the results has been provided today.
Please test my pet for heartworm, lyme disease, ehrlichia and anaplasma today (4DX)

Biopsy Release

If your pet is here for removal of a mass or lump, we recommend submission of the mass for analysis. The cost for this submission should be included in your procedure estimate. If it is not listed, please call the office or ask a staff member at drop off.

Biopsy Release *

I approve the recommended biopsy submission
I decline the recommended biopsy submission work at this time and understand that a definitive diagnosis of the mass/lump cannot be given without this test.
Not applicable to my pet.

Home Again Microchip

The best time to microchip your pet is when your pet is under anesthesia. The chip is about the size of a grain of rice and is considered to be the best form of permanent identification. Would you like to have your pet microchipped today? **Please note that all pets adopted from Blue Chip will be implanted with a microchip unless one is already present. This was included in your adoption fee.**

Microchip *

Elizabethan Collar

Your pet cannot be allowed to lick at the incision. An Elizabethan Collar is recommended to prevent licking and chewing at the surgical site. This will help minimize the likelihood of self-trauma to the incision site, which can result in the need for further procedures. **If your pet is here through Blue Chip Farm Animal Rescue, these collars ARE NOT paid for by them.

E-Collar *

Please fit my pet with an elizabethan collar
I decline the recommended elizabethan collar

Anesthetic and Surgery Release

I understand and consent to recommended anesthetic procedures stated above. The nature of such services has been described to me to my satisfaction. I understand that the administration of anesthesia involves some risk to my pet, including rare reactions to medications and death. I authorize Creekside Animal Hospital to perform medical and diagnostic procedures on the animal identified in this record as required for diagnosis and treatment. I understand that all procedures and surgery also involve some risk to my pet. The most common risks include, but are not limited to the following: bleeding, nerve damage, and infection. I also understand that no guarantees or assurances have been made regarding the outcome of this procedure. The doctors and staff of Creekside Animal Hospital will use all reasonable precaution against injury, escape, complications, and death. I agree to not hold the doctor and staff responsible under any circumstances. I understand Creekside Animal Hospital is not a 24-hour facility and is not staffed by medical team after hours. If your pet requires continuous 24-hour care, we recommend transferring your pet to a local Emergency and Specialty facility. I understand that I assume financial responsibility for all services rendered, and that payment is due on the day of service. *

I have read, understand, and authorize

In the event that a life threatening emergency should arise, I: *

Authorize veterinary staff to perform lifesaving measures.
Prefer veterinary staff not perform lifesaving measures.

Flea Treatments: I understand that if my pet has evidence of a flea infestation, medication will be given to kill all adult fleas at my cost. *

I understand

Sterilization Identification: I understand that if my pet is being spayed or neutered today, a small permanent mark will be made in the skin adjacent to the incision. *

I understand

Signature of Owner/ Agent *

Clear Signature

Date *

Anesthesia
Consent Form

Anesthesia Consent Form

Pet Information

Contact Information

Pre-Anesthetic Blood Work Release

Biopsy Release

Home Again Microchip

Elizabethan Collar

Anesthetic and Surgery Release

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