Anesthesia and Surgery Consent Form
Reason(s) for anesthesia ______________________________________
I hereby authorize and direct the Veterinarian(s) at Henderson Animal
Care Hospital, P.C. to perform the above procedure(s) and additional diagnostic
and/or treatment procedures as deemed advisable or necessary for my pet.
The nature of the procedure(s) has been explained to me and no
guarantee has been given as to the results or cure. I understand that there may
be risks involved in these procedures. Communication between the doctor and
the pet owner is essential to the best possible veterinary service. (Please feel
free to discuss all aspects of your pet’s treatment and its cost.) I understand
that a written estimate of the costs is available upon request if one has not
already been presented to me.
Payment is to be made when the service is performed or when I take my
pet home. I agree to pay in full for services rendered, including those deemed
necessary for medical and/or surgical complications or unforeseen circumstances.
Any Estimate of charges for presently planned procedures is only an
approximation and the final bill may be greater or less than this amount.
Owner/Agent Signature: _________________________________
We will perform a complete physical exam on your pet before
administering the anesthesia. Depending upon the age of your pet and its
overall health, we recommend additional blood tests be performed. By
performing this important pre-anesthesia blood profile, we may be able to detect
pre-existing internal problems that may not be evident physically, but could lead
to serious complications. Additional tests needed will be determined by the
doctor at the time your pet is dropped off for surgery.
Please indicate if you would like pre-anesthetic bloodwork by signing
the appropriate statement below.
Please complete the blood work you recommend prior to anesthetizing my pet: ______________
I decline all pre-anesthetic bloodwork: ____________________________________