Anesthesia/Surgery Consent Form

Client Name*
First Last
Patient Name*
Species*
Breed*
Date of Birth*
MM slash DD slash YYYY
Age*
Sex*
Your pet will be undergoing general anesthesia plus a surgical procedure today. Please review the consent and do not hesitate to inform us of any questions or concerns you may have.
Pre Anesthetic Blood Work
In order to recognize any underlying abnormalities your pet may have, we recommend having a pre-surgical profile run on your animal. Pre-anesthetic blood work checks the internal organs and blood count and is a vital part of safe anesthesia. Help us provide the best level of care for your pet by choosing to perform blood work prior to anesthesia or sedation. Please note, some procedures REQUIRE bloodwork. The staff at AVMC will review this with you when applicable.*
- I authorize bloodwork
- I decline blood work and understand there are increased risks during anesthesia
Authorization and Risk Assessment. Please initial after each statement below
I understand that unforeseen conditions may be revealed during the procedures that may require more extensive or different treatments. I understand that all reasonable efforts will be made to contact me to authorize any additional treatments. However, if these efforts are unsuccessful, I authorize the performance of any procedures or treatments that are deemed immediately necessary for the health and wellbeing of my pet in the professional opinion of the attending veterinarian.*

(initial here)
I understand that I assume financial responsibility for all services rendered.*

(initial here)
The veterinarian has described the procedures to be performed and has explained to my satisfaction the purpose for performing them and the risks involved with them. I realize that there can be no guarantee as to the outcome of any procedures.*

(initial here)
I hereby authorize anesthesia/surgery for my pet. I understand that some risks always exist with anesthesia and/or surgery. My signature on this consent form indicates that any questions have been answered to my satisfaction. While Advanced Veterinary Medical Center provides the highest quality of anesthesia monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical procedure. In particular, I have been advised that there is an extremely small risk of death, complications, or side effects (which can present themselves well after the procedure) every time an anesthetic is used and that I have been advised of the possibility. I acknowledge these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I will not hold Advanced Veterinary Medical Center, the veterinarians, or any staff member liable for any complications that may arise.*

(initial here)
Consent for CPR or DNR:
In the case that your pet were to suffer cardiac and/or pulmonary arrest (heart or breathing stops), do you authorize us to provide Life-saving measures (i.e. cardiopulmonary resuscitation)? Costs of these services can be $500 and are NOT reflected in this estimate. If you choose to allow these procedures for your pet, you will be contacted as soon as possible to be informed of the situation and given the options how to proceed.
Pick one:*
- CPR I authorize appropriate life saving measures. I understand and assume all financial responsibility for this.
- DNR I do not wish for life saving measures to be employed. I am electing “Do Not Resuscitate” status for my pet.
Emergency Contact Phone*
I have read and understand this authorization.*

(Owner/Authorized Agent Signature )
Date*
MM slash DD slash YYYY

Cookie	Duration	Description
cookielawinfo-checkbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.

Call Now 408-956-8061

Pre Anesthetic Blood Work

Authorization and Risk Assessment. Please initial after each statement below

Consent for CPR or DNR: