Anesthetic Consent Form | Quioccasin Veterinary Hospital in Richmond, VA

AUTHORIZATION AND CONSENT FOR DENTAL, SURGERIES, AND ANESTHETIC PROCEDURES

Client's Name(Required)

am the owner (or agent of the owner) of,

Pet's Name(Required)

I authorize and request you to hospitalize this animal for purposes of diagnosis, treatment, surgery, dental, or other procedures, as specified by this release and approve the use of whatever anesthetics you deem advisable for the well-being of the animal. I understand that you will use reasonable precautions to assure the animal’s safety while it is in your care but will not hold you responsible if it should injure itself, escape, fail to eat, become ill, or die. I absolve you of all liability arising from the performance of procedures requested herein. I understand the anesthetic and surgical, diagnostic, or therapeutic procedures may involve risk of complications, injury, or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure. Furthermore, I authorize the hospital staff in an emergency situation, to follow through with such procedures as are necessary from the well-being of my pet on a continuing basis until further communication with me. I agree to assume financial responsibility for all routine and emergency services rendered.

I understand that prior to my pet’s procedure, a pre-anesthetic examination and bloodwork are performed to screen for any potential pre-existing condition which might complicate the anesthetic event. Electrocardiograms are performed on dogs prior to anesthesia. I accept responsibility for the charge associated with these necessary procedures.

Initial(Required)

When did your pet last eat?(Required)

Procedure(s) to be performed(Required)

Please indicate if your pet is on any medication(s) or supplements:(Required)

If yes, what medication(s) and when last given?

If the hospital staff or doctor calls and cannot reach me by phone, please do the following:(Required)

Do whatever is necessary and recommended by the veterinarian at this time to avoid a second anesthetic procedure.

Do NOT perform any additional procedures at the time.

If problems unrelated to the authorized anesthetic procedure(s) are found that require ELECTIVE correction, I may be reached by the following phone number(s):(Required)

Additional Services

Please indicate if you would like to have any of the following services performed while your pet is under anesthesia:

I would like a Home Again Microchip implanted(Required)

Yes

Decline at this time

Patient is already microchipped

So that we may register your pet, please provide the following information:

Email Address(Required)

Alternate Contact Name(Required)

Alternate Contact Phone Number(Required)

*Please ensure the alternate contact is someone other than yourself

Additional Services?(Required)

Nail Trim

Anal Gland Expression

Ear Cleaning

None at this time

FOR PETS UNDER THE AGE OF 12 MONTHS

Additional Services?(Required)

Floride Treatment

Extraction of retained deciduous (baby) teeth

None at this time

If you do not wish to have any additional services performed, please sign here:

CPR or DNR Consent

CPR means Cardio Pulmonary Resuscitation and is the treatment or resuscitation of a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet who has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of a pet with no heartbeat.

CPR Consent(Required)

Decline

Owner's Initials(Required)

DNR means Do Not Resuscitate. This means if a pet stops breathing or the heart stops, no effort will be made to attempt to revive the pet, and the pet will die.

DNR Consent(Required)

Decline

Owner's Initials(Required)

Authorization

IF YOUR PET IS SCHEDULED FOR A DENTAL PROCEDURE, PLEASE READ AND INITIAL BELOW:

I acknowledge that if I cannot be reached during a dental procedure, I authorize any necessary procedures. These may include dental radiographs, extractions, minor oral surgery, or gingival biopsy.

Initial

Your signature below constitutes your acknowledgment, as the owner or the owner’s agent, that you have read and agreed to the above, that the procedure(s) have been explained to your satisfaction, and that you authorize and consent to the performance of the procedure(s) and to the administration of anesthesia.

Patient Name(Required)

Owner Name(Required)

Signature(Required)

Date of Appointment(Required)

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