Anesthesia Consent Form

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Anesthesia Consent Form

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Owner's Name *

First

Last

Pet’s Name *

Anesthetic Procedure to be performed

I, the undersigned owner or agent of the pet identified above, authorize the veterinarians at Sachse and/or Murphy veterinary hospitals to perform the above indicated procedure(s). I understand that some risks exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarians before procedures are initiated.

Pre-Anesthetic blood work ($45-65)

We offer pre-anesthetic blood work to help identify any areas that may be of concern for your pet during anesthesia. All animals will benefit from blood work, but it's mandatory for all pets over the age of 7.

Yes, I would like to ensure that my pet does not have any pre-existing health problems that can be identified with blood work that might adversely affect the anesthesia.
No, I do not wish to have blood work performed on my pet.

Antibiotics/Pain Meds (price varies based on product, pet's weight, and duration needed)

In some situations, antibiotics and/or pain relievers may be indicated.

Yes, I approve the dispensing of antibiotics and/or pain relievers.
No, I do not approve the dispensing of antibiotics and/or pain relievers.

Microchip ($69, includes implant and 1 year registration with Home Again)

A microchip provides permanent identification of your pet and aids in their safe return in case of loss or theft.

Yes, I want a microchip
No, I do not want a microchip
My pet is already microchipped

Nail Trim ($9-11)

Yes, I would like my pet's nails trimmed.
No, I would not like my pet's nails trimmed.

Add a Dental Cleaning ($90-$135 plus add'l anesthesia time)

Having your pet's teeth professionally scaled and polished is critical to their overall health. This can easily be done while you pet is already under anesthesia

Yes, I would like to add a dental to today's procedure
No, I would not like to add a dental to today's procedure.

Cold Laser Therapy ($10)

The cold laser works to reduce inflammation at the surgical site, which will in turn help reduce pain. It also increases blood flow to the site which will help speed healing time.

Yes, I would like cold laser therapy
No, I would not like cold laser therapy

For Dental Patients ONLY

Dental Radiographs (x-ray) and Tooth Extraction

During the course of a dental examination, our doctors may determine that some teeth have been compromised and therefore may need digital x-rays and/or should be removed. This included baby teeth that have not fallen out on their own.

Yes, I authorize x-rays of loose or compromised teeth ($69.18 first, $54.54 each additional)
Yes, I authorize full mouth x-rays ($169.08)
No, I do not authorize dental x-rays of any kind
Yes, I authorize the removal of teeth ($4/min)
No, I do not authorize removal of teeth

While I accept that all procedures will be performed to the best abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I understand that prices quoted for such procedures are for non-complicated procedures and that any unforeseen complications may result in further cost. I assume financial responsibility for all charges incurred and I consent release of medical information for the animal.

I have read and fully understand the terms and conditions set forth above.

Signature

Clear Signature

Date

Phone

Anesthesia Consent Form

Anesthesia Consent Form

CLICK HERE PDF FORM DOWNLOAD

For Dental Patients ONLY

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