Surgery/anesthesia Consent Form printable pdf download

Surgery/Anesthesia C onsent F orm

Anesthetic and surgical procedures to be performed:

I, the undersigned owner or agent of the pet identified above, authorize the veterinarian(s) at The Veterinary Center

of Hudson to perform the above procedures. I understand that some risks always exist with anesthesia and/or

surgery, and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian(s)

before the procedures are initiated.

In order to provide the best care available for your pet, we strongly recommend pre-anesthetic blood work to

help identify any underlying metabolic/systemic abnormalities. All animals will benefit from the blood work, but

we strongly urge all large breed dogs over 5 years of age and all small breed dogs and all cats over 7 years of

age have complete blood work performed prior to any anesthetic procedure.

_ __

Yes, I would like to identify any pre-existing health problems that might adversely effect the

anesthesia.

___

No, I do not wish to have any blood work performed on my pet.

In some cases where tissue is removed, examination of the tissue by a pathologist may be indicated.

___

Yes, please submit tissue for histopathology.

___

No, I do not desire histopathology.

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand

that no guarantee or warranty has been made regarding the results that may be achieved. I understand that any

prices quoted for such procedures are for non-complicated operations and that any unforeseen complications may

result in further cost. I assume financial responsibility for all charges incurred to patient, and I consent to the release

of medical information for the said animal. I have read and fully understand the terms and conditions set forth above.

____

The undersigned owner or agent of the pet identified above, certify that I am

I am not ____ (check one)

eighteen years of age or over and authorize the veterinarian(s) at The Veterinary Center of Hudson to perform the

above procedures.

**All pain medications and antibiotics are included in your anesthesia cost.**

My signature on this form indicates that any questions I have regarding the following issues have been answered to

my satisfaction:

- The reasonable medical and/or surgical treatment options for my pet

- Sufficient details of the procedures to understand what will be performed

- How fully my pet will recover and how long it will take

- The most common and serious complications

- The length and type of follow-up care and home restraint required

- The estimate of the fees for all services

- Any necessary payment arrangements

I agree to pay a deposit of the estimated fees if needed, assume financial responsibility for the remaining fees, and

provide payment via cash, credit card, or check at the time my pet is discharged from the hospital.

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me,

the staff has ___

does not have ___ (check one) my permission to provide such treatment and I agree to pay for

such services. I have read and fully understand the terms and conditions set forth above.

Surgery/anesthesia Consent Form

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