Surgical and General Anesthesia Consent Form 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:* MM slash DD slash YYYY 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 $150.* 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 and Da2pp/FVRCP, 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 $80.00 fee to your estimate.* Yes No We recommend the use of an e-collar or pet protective shirt for post-operative patients with an incision. Would you like to purchase one today? Yes or No* Yes No Disclaimer: For some procedures a hard e-collar may be necessary.Please add the following: E-collar* Yes No Pet Protective Shirt* Yes No Do you feel your pet would benefit from Trazodone, a medication to aide with post-operative confinement anxiety? This would include an additional charge not included on the estimate. Yes or No.* 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* Reset signature Signature locked. Reset to sign again Δ In
