Anesthesia Release And Surgical Consent Form printable pdf download

Anesthesia Release and Surgical Consent Form

Pet’s Name: _________________________

Date: _________________________

Owner: _______________________

Phone Number: ______________________

Procedure(s): ____________________________________________________________

Anesthesia Release

I understand that my pet’s procedure requires general anesthesia and /or sedation. All precautions

will be taken to insure the safety of my pet. However, I have been informed of the possible risks

associated with anesthesia /sedation, and that I am responsible for associated charges. I also

understand that the doctor(s) reserve the right to perform lifesaving efforts should complications

arise. I officially release Asheville Highway Animal Hospital of any liability pertaining to this

procedure (before, during, or after surgery).

Print Name: ____________________

Signature: __________________________

Diagnostic Screening

With all anesthetic procedures, problems can arise due to pre-existing conditions not evident

during routine pre-anesthetic examinations. To avoid these problems, we require that all

patients 6 years and older be screened prior to anesthesia by means of the following

laboratory test. We highly recommend this screening be done for all patients regardless of age.

Please approve or decline by initialing and signing below.

Approve_____ Decline_____ Screening Panel Plus (This checks for: anemia, problems

clotting blood, hidden infections, kidney or liver

problems, low blood sugar, dehydration.)

Print Name: ____________________

Signature: __________________________

Additional Services

Please note any additional services that you would like

us to perform while your pet is anesthetized.

___Nail Trim

___Teeth Brushing

___Heartworm Test

___Microchipping

___Full Dental Cleaning

___Feline Leukemia Test

___Ear Cleaning

___Growth Removal

___Anal Gland Expression

Anesthesia Release And Surgical Consent Form