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.

Name *

First

Last

Email *

Your Pet's Name *

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

Did your pet receive a pre-surgical oral dose of Cerenia (anti-nausea medication) last night (dogs only)? *

Yes
No
No, and I would like the veterinarian to administer an injectable version of this medication prior to anesthesia (*there is an additional fee*)

When did your pet last eat? *

Does your pet have any known medication or drug allergies? *

In the past 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? *

Please let us know what option you would like to help protect the incision from your pet licking or chewing on it:

Elizabethan Collar (Cone)
Medical Pet Shirt
KONG Cloud Collar
Elizabethan Collar AND Medical Pet Shirt

Please select any services you would like performed while your pet is under anesthesia (check all that apply):

Nail Trim ($11.30)
Anal Gland Expression ($19.31)
Laser/Electrocautery Surgical Option ($59.40)
Microchip and Microchip Enrollment ($77.45)
Take home medication for additional sedation (~ $27.00)

Please initial after reading the following text: 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** *

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.

Our greatest concern is the well-being 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 an agent acting on the 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 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 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. Please sign, recognizing that you have read and understood the risks.

Date *

Surgery and Anesthesia Consent

Surgery and Anesthesia Consent Form

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