ANESTHESIA CONSENT
FORM FOR SURGERY
|
If
you prefer to download our PDF form
instead of using our online form,
please click the link below and fax
the completed form to 804-794-3015.
Anesthesia
Consent Form for Surgery
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For the SAFETY and
COMFORT of our patients, and for the
peace of mind of our clients, we have
a minimum set of requirements before,
during and after anesthesia. Additional
care that may be necessary in some
cases is outlined below.
While estimates accurately reflect
services they can not reflect unforeseen
circumstances. While we attempt
to be accurate it can not include
unforeseen circumstances (all efforts
will be made to contact you if this
occurs). |
For SAFETY we require
the following:
- A pre-surgical exam (done on the
day of surgery)
- An IV catheter will be placed
for intravenous access for fluids
and/or medications
- Advanced monitoring of vital systems
- Intravenous fluids during surgery
to maintain blood pressure
- Baseline lab tests of blood within
six months of procedure to determine
underlying problems and metabolism
of anesthesia
Advances in anesthesia and surgery have
made most procedures quite safe, with
a low risk of complications. However,
occasional problems can arise if the
veterinarian is not aware of pre-existing
conditions which may not be evident
during the pre-surgical exam and diagnostic
testing. We require that every
pet undergoing general anesthesia have
baseline lab testing within 6 months
of procedure. This does not guarantee
the absence of complications; however,
it will greatly reduce the risk of complications.
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For COMFORT we
require the following:
- Post procedure anti-pain injection
- Pain medication for home administration
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| For Additional Safety
we recommend a chest x-ray and an EKG
to check heart size and function. |
| |
Yes, I would like pre-surgical chest
x-rays. ($140.00)
Yes, I would like a pre-surgical Electrocardiogram
(EKG) ($150.00) |
| For your convenience we
offer the following additional services.
Some are easier and more comfortable
for your pet if performed while under
anesthesia. |
| |
Yes, I would like a microchip placed
during anesthesia. ($52.00)
Yes, I would like a fecal examination
done to check for intestinal parasites.
($23.00) |
|
I am the owner or authorized agent and
hereby authorize Midlothian Animal Clinic
(doctors and staff) to administer treatment
and anesthesia as determined by the
attending veterinarian. Further,
I understand why such diagnostic, medical,
and/or surgical procedures are being
performed. (Their advantages and
possible complications, as well as possible
alternate treatments, are either made
or implied). I am aware that veterinary
monitoring is not provided overnight.
I further authorize emergency
treatment if necessary without my prior
approval. |
| Where can we reach you today? |
(Phone Number) |
