Surgical Consent Form (Page 2 of 3) in pdf

Animal Clinic of Council Bluffs Surgical Consent Form Continued

We offer 2 types of anesthetic gases for surgery. Isoflurane is the standard gas but Sevoflurane is

available for an added fee of $25.00. Sevoflurane allows your pet to wake up faster and easier after

surgery. Which anesthetic gas do you prefer we use for your pet?

□

Sevoflurane

Isoflurane

In the event of an emergency, a pre-placed intravenous catheter allows more rapid administration of

life saving drugs. All patients undergoing surgery will have a catheter in place.

YES, I have read the above sentence and I understand__________.

(initial)

Our pets do not show pain as we do. They do not complain as loudly as we do and they accept the

levels of pain that we could not imagine. It has been shown that humans recover better and faster if

they are pain free. It is the same for our pets. We will be administering additional pain relief

medication, and there will be a corresponding charge on your bill.

YES, I have read the above sentence and I understand__________.

(initial)



Please list any medications that your pet is taking.



Did you give any medications today?



Last meal? Last water?

I understand that there are risks associated with the procedures set forth above, and with anesthesia,

and I am satisfied after speaking with the staff of Animal Clinic of Council Bluffs that they will treat the

patient as they deem necessary for the patient’s health, safety, and well being; however I do

understand that no guarantee of successful treatment can be made. Animal Clinic of Council Bluffs is

authorized to dispose of said animal unless the owner, or authorized agent of the owner, calls for and

pays all accrued charge on said animal within seven (7) days after notification that a pet is ready to be

released from the hospital.

I acknowledge that I have read and fully understand this authorization for medical treatment, the

reason why such medical treatment is considered necessary, as well as its advantages and possible

complications, if any.

Signature of owner/agent of owner________________________________ Date__________

Emergency Telephone Numbers where I may be reached at today:

#1 ____________________________ ( home / cell / work )

#2 ____________________________ ( home / cell / work )

#3 ____________________________ ( home / cell / work )

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Surgical Consent Form Page 2