I certify that I am the owner or responsible party for the pet listed below. This pet is being assessed or admitted today for a general anesthetic and/or surgical procedure. *

I have read and agree

Owner Name *

First

Last

Email *

Pet's Name *

Best number to reach you on the day of your pet's procedure *

When did your pet last eat? *

Does your pet have any known medication or drug allergies?

In the last 48 hours, please select if your pet has experienced any of the following:

Is your pet on any medications? If so, please list the medications and when they were last given. *

Do you have any additional concerns for the doctor today?

We strongly recommend that you purchase an elizabethan collar for use at home to help prevent your cat from licking and/or chewing on his/her incisions. Please indicate if you need to purchase an elizabethan collar:

Yes, please send my pet home with an elizabethan collar (Cone)* additional charge
No, I decline to purchase an elizabethan collar. I understand that my pet may cause significant damage to his/her incisions up to and including completely chewing open the incision requiring additional anesthesia and surgery.

Would you like a microchip placed while your pet is under anesthesia today?

Yes, I request a Microchip and Microchip Enrollment ($77.45)

I understand that every patient has a different threshold for pain. If needed, additional pain medication will be given following the procedure if deemed necessary by the veterinarian. **If administered, there will be an additional charge for this medication** I also understand that additional medications to help improve blood pressure and/or heart rate may be given during the procedure if deemed necessary by the veterinarian. **If administered, there will be an additional charge for these medications** *

I have read and understand the above

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedures today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference: *

Please proceed with life-saving measures. I will accept responsibility for all costs incurred.
Please do not proceed with life-saving measures. I accept responsibility for this decision and understand that severe complications up to and including death could occur if life-saving measures are not used.

Anesthesia Consent

Our greatest concern is the wellbeing of your pet. Before any anesthesia is administered, we will perform a complete pre-anesthetic examination to identify existing medical conditions that could complicate the procedure and compromise your pet’s health. There is always the possibility that a pre-anesthetic exam alone will not identify all health problems. This is why blood testing is required prior to anesthesia.

I, (or agent acting on owner’s behalf) hereby authorize Andover Animal Hospital (or its agents or whomsoever is designated) to perform the above procedure. I understand that there are inherent risks with anesthesia and that a guarantee of a successful outcome cannot be made. These risks have been explained to me as completely as possible within reason. *

I have read the above and understand the risks

I also understand that Andover Animal Hospital will do their best to minimize these risks through pre-anesthetic blood testing, using the most appropriate and safest anesthetics available, and by using state of the art monitoring equipment. Furthermore, I agree to pay the fees for all services rendered at the time the pet is discharged from the hospital. *

I have read the above and agree

I have been informed that all surgical patients must be picked up prior to the end of the business day. If unforeseen circumstances require me to arrive to pick up my pet after hours, I will notify Andover Animal Hospital immediately. I understand that if my pet has not been picked up prior to the end of the business day and I have not made any attempts to communicate with Andover Animal Hospital, my pet may be hospitalized overnight. I understand that there are no employees here overnight to monitor my pet. *

I have read the above and agree

Signature *

Clear Signature

Date *

Declaw and Anesthesia Consent

Declaw and Anesthesia Consent Form

Anesthesia Consent

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