Surgical and General Anesthesia Consent Form

Please indicate what type of surgery your pet is having:*

Spay
Neuter
Dental
Other

Other*

*

I hereby consent and authorize the doctor(s) at Crossroads Animal Hospital to perform the above procedure(s).

Appointment Date:*

Owner’s Name*

First Last

Best Number to reach you today*

Pet’s Name*

*

I authorize the use of professionally accepted general anesthesia to perform the above procedures or surgery as deemed necessary by the doctor(s). I understand that support personnel will be used as needed by the veterinarian.

*

I have been advised as the nature of the above procedures and the risks involved in performing general anesthesia to the above animal. I realize results cannot be guaranteed. I understand that most medical and surgical procedures are accompanied by some risks (including death), especially when anesthesia is used.

If an emergency arises please perform CPR and other life saving measures. By allowing the doctor(s) and staff at Crossroads Animal Hospital to perform CPR, there are additional charges for which I will be responsible. CPR for the first 15 minutes averages $100.*

I accept
I do not accept

My pet was fed after 12:00 a.m.*

Yes
No

Known allergies or sensitivities to medication/anesthetics*

Please name any medication(s) your pet is currently taking. List the last date and time that it was given.*

*

I understand that if my pet is not currently vaccinated for rabies, my pet will be vaccinated today at Crossroads Animal Hospital for an additional charge that I am responsible for.

*

I understand that if my pet is found to have fleas, a medication will be administered that kills all adult fleas. I am responsible for the cost if the medication.

We offer complimentary nail trims for animals that are anesthetized. Would you like your pet’s nails trimmed?*

Yes
No

Would you like to have your pet microchipped today? This is an additional $65.00 fee to your estimate.*

Yes
No

*

I have read and understand this authorization and consent. I further understand that I assume full financial responsibility for all services rendered.

Signature*

Make an Appointment

(540) 832-1751

Surgical and General Anesthesia Consent Form

Surgical and General Anesthesia Consent Form

Crossroads Animal Hospital

Hours of Operation

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Days	Hours
Monday	7:30AM – 6:00PM
Tuesday	7:30AM – 6:00PM
Wednesday	7:30AM – 6:00PM
Thursday	7:30AM – 6:00PM
Friday	7:30AM – 6:00PM
Saturday	Closed
Sunday	Closed