Anesthetic Surgical Consent Form printable pdf download

ANESTHETIC & SURGICAL CONSENT FORM

Calhan Veterinary Clinic

P.O. Box 149 Calhan, CO 80808

(719) 347-2702

Date_____________

Owner’s Name __________________________________________

Address, City, State, Zip__________________________________________________

Telephone (home) ______________________ (work) ________________________

Pet’s Name____________________________________________

Species_________ Breed___________ Age_________ Sex___________

Pre-anesthetic blood work: Pre-anesthetic blood work is strongly recommended for all patients undergoing

anesthesia. A simple blood test, performed in-house will tell us about your pet’s liver and kidney function, and

allow us to tailor our anesthetic protocol to your pet. Our minimum testing will include:

CBC – assesses possibility of anemia, clotting problems, or infection

ALT – (liver)

ALP – (liver)

BUN – (kidney)

CREA – (kidney)

GLU – (sugar)

TP – (hydration)

Pre-anesthetic blood work: [ ] Yes [ ] No If declining, please initial here: _______

The procedure(s) being performed today is/are______________________________________________. I

hereby give consent to perform general anesthesia and the above procedure(s) on the indicated patient. I

understand that some risks always exist with anesthesia and surgery, and that I am encouraged to discuss

any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are

initiated. My signature on this form indicates that any questions I have regarding the procedure(s) and

anesthesia have been answered to my satisfaction.

______________________________________________________

Signature of owner/agent

Date

Please indicate if your pet requires any vaccinations or deworming:

Dogs: [ ] Distemper/Parvo combination [ ] Rabies [ ] Bordetella

Cats: [ ] Feline upper respiratory [ ] Feline Leukemia [ ] Rabies

Deworming: [ ] Yes [ ] No

Heartworm test: [ ] Yes [ ] No

Anesthetic Surgical Consent Form