Metropet Veterinary Clinic Online Form Anesthetic Surgical Consent printable pdf download

MetroPet Veterinary Clinic Online Form: Anesthetic/Surgical Consent Form

Client Name: _______________________________

Date: _________________________

Pet Name: ___________________ Age: _________________

At MetroPet Veterinary Clinic, your pet’s health, safety, and comfort are our primary goals. In order to better help you understand the

options available to you and your pet at the time of surgery/anesthesia, please carefully read the recommendations below. Please

initial the line if you would like any of these optional items provided for your pet and sign the form below. If you do not wish have any of

these items, please initial the line at the bottom of this page stating so and sign the form. Thank you for your cooperation and please

ask if you have additional questions.

______Preanesthetic blood work ($95.00). We need to make sure there aren’t any underlying problems that could potentially

negatively affect the animal while under anesthesia. This blood work briefly checks the liver, kidneys, and blood sugar to screen for “red

flags” prior to anesthesia. Since the liver and kidneys process anesthetic drugs in the body, if they are not working correctly, there can

be anesthetic complications.

______Home again Microchip ($ 45.00 ): This is recommended for all pets. Unfortunately many people lose their animals each year.

Some get out of the house, and can’t find their way home and others are actually stolen. Whatever the reason, we want these pets to

return home safely. This microchip has reunited hundreds of pets with their owners. It is a tiny chip that is placed under the skin in

between the shoulder blades. If someone finds your pet and brings it to a shelter or hospital they will scan them first to see if they have

a chip and therefore an owner.

______Feline Leukemia/Feline AIDS (FIV) Combination Test ($52.25): Stray cats, feral cats, barn cats, and cats with an unknown

history that have been living outdoors are at the highest risk of contracting these diseases. These diseases may be spread between

cats and cause suppression and failure of the immune system and in some cases may be fatal. A cat with feline leukemia or FIV would

need additional precautions to be taken prior to routine anesthesia and surgical procedures.

______Placement of an Intravenous (IV) Catheter and Fluids ($ 60.23): It is a good precaution to have an IV catheter in place during

any surgical procedure. However this may be further warranted in older or sick animals who are more likely to have anesthetic

complications. Having an IV catheter in place would allow the doctor to more quickly administer life saving drugs and IV fluids for CPR

in the event that your pet has a complication with anesthesia.

______Pre-Anesthetic ECG Screening ($24.27): This test will check for abnormalities in the heart rate and rhythm such as arrhythmias

that can lead to anesthetic complications and sudden death. It is recommended to pre-screen pets for arrhythmias of the heart prior to

anesthesia.

______I authorize anesthesia or sedation and/or surgery for my pet. The nature and the risks of this procedure have been explained to

me. I understand that there are always some risks with anesthesia and I am encouraged to discuss any concerns that I have prior to

the procedure or anesthetic. My signature on this consent form indicates that any and all of my questions have been answered to my

satisfaction and that you have my express informed consent to administer anesthetics and/or perform procedures or surgery on my pet.

MetroPet Veterinary Clinic provides the highest quality of anesthetic monitoring and surgical services, and we will do everything

possible to reduce any risks. I understand the risks and will not hold any veterinarian, team member, or MetroPet Veterinary Clinic

liable for any complications that may arise.

______I DO wish to have some of the items provided for my pet during surgery/anesthesia. Only the initialed items will be provided.

Signature:__________________________________ Print Name: __________________________________

______I understand the risks involved with anesthesia and I DO NOT wish to have any of the optional items provided for my pet.

Signature:_________________________________ Print Name: ___________________________________

It is very important that I can be reached at any time today.

Contact me at the following phone number ____________________ or alternately at

__________________

Metropet Veterinary Clinic Online Form Anesthetic Surgical Consent