Anesthesia/Surgery Consent Form

Rustic Line

Owner and Pet Details

Owner's Name(Required)

Pet's Name(Required)

Phone Number

It is important that we have a phone number where you can be reached if consultation is necessary while your pet is under anesthesia.

Anesthesia/Surgery Services

Your pet will be undergoing general anesthesia and/or a surgical procedure today.

In order to recognize any underlying abnormalities your pet may have, we recommend having a pre-surgical blood profile run on your animal.

This consists of a CBC, which will check blood cells, and an ALT, ALKP, CREA, GLU, TP, and BUN, which will check blood glucose, kidney and liver enzymes.

These blood tests will help us to assess the health status of your pet more completely and determine if there are any additional precautions we need to take before surgery. We highly recommend a blood profile for geriatric animals (animals older than 7 years).

There is an additional charge for these blood tests. We hope you understand the need for these important tests.

Wish to have the pre-surgical bloodwork run today?(Required)
Wish to have post-surgical pain medication for my pet?(Required)
Wish to have laser therapy?(Required)
The use of specific wavelengths of light to stimulate the body’s natural ability to heal.

Additional Services

While your pet is in our hospital, would you like any additional services?
Google Micro-chip Implant(Required)
A permanent chip placed under your pet's skin, which identifies your pet and is read by a scanner. Local animal shelters are equipped with these scanners.
Heartworm Test(Required)
Flea Treatment(Required)
Nail Trim(Required)

Disclaimer

I, the undersigned owner or authorized agent of the above patient, hereby authorize the staff of Fairlea Animal Hospital to administer necessary treatment and to perform medical procedures.

I further understand that no guarantee of successful therapeutic or diagnostic outcome is made.

I also assume financial responsibility for all charges incurred, and agree to pay all charges at the time of release.

***ALL ANIMALS ADMITTED MUST BE CURRENT ON THEIR VACCINATIONS AND MUST BE FREE OF EXTERNAL PARASITES. ANY ANIMAL FOUND TO HAVE FLEAS OR TICKS WILL BE TREATED AT THE OWNER'S EXPENSE.***

Owner or Authorized Agent's Name(Required)