Everhart Veterinary Hospital
410-355-3131
Surgery and Anesthesia Consent Form
Client Name:
Patient Name:
Procedures to be performed: ______________________________________________
Hospitalization/Surgical Information:
Preparation- The skin around the surgical area will be clipped and scrubbed with an antiseptic.
Sterile procedures will be followed.
Anesthesia- Pre-surgical blood work and physical exam will enable us to assess and minimize
risk of anesthesia for your pet. For routine, elective procedures, young, healthy pets are not
required to have pre-anesthetic blood work. However, to further assess anesthetic risk in your
pet, we do recommend that ALL pets have pre-anesthetic blood work prior to surgery. This
blood work checks your pet’s organ function, most importantly the liver and kidneys, which are
the main organs that process anesthetic drugs. If the blood work is abnormal, we then know that
your pet’s health would be at risk by placing him/her under anesthesia. The additional cost of
the pre-anesthetic blood work starts at $49.50 and will be done prior to surgery. You will be
called if there are any abnormalities. If the blood work is normal, we will proceed with surgery.
*Certain circumstances may arise where the Veterinarian may recommend a more
extensive blood panel at an increased cost. Your pet’s age, health status, and procedure to
be completed are taken into consideration to determine which panel is sufficient. Any
changes should have been discussed in the Treatment Plan prior to surgery.
________
Yes, I would like pre-anesthetic blood work performed on my pet.
________ No, I would not like pre-anesthetic blood work performed on my pet. However, if
your pet is 5 years or older, labwork is required to check liver and kidney values.
Pain Management: It is important to keep your pet comfortable during and after surgery.
Therefore, your pet will be given pain medication at the time of surgery and, in most cases, will
also be sent home with pain medication. The additional charge for routine surgical pain control
is between $42 and $60.
Please Initial: _______________
Treatment: In order to keep your pet and other hospital patients healthy, your pet will be
treated for any contagious parasites. These include, but are not limited to, fleas, ticks, ear mites,
lice, and intestinal parasites. The additional charge for this treatment is between $10 and $30
depending on the parasite found.
Please Initial: _______________
Catheterization- For most surgical procedures, an intravenous catheter is placed to provide us
with an easy route to administer medications and fluids (which support kidney function and
blood pressure) during the procedure.
Monitoring: We further minimize anesthetic risk by monitoring heart rate and rhythm,
respiratory rate and quality, blood pressure, oxygenation, and depth of anesthesia during the
procedure.
Microchipping: If you have not already done so, we like to offer to microchip your pet while
your pet is already undergoing anesthesia. Although the procedure is only mildly uncomfortable
and is fairly quick, many of our clients want to make sure this is completely painless for their
pets and appreciate being able to get this done during another procedure). The cost is $45.00 for
the implantation and the Microchip. However, you will need to register your chip with
HomeAgain for a separate annual fee payable to HomeAgain.
________
Yes, I would like Everhart Veterinary Hospital to Microchip my pet.
________
No, I would not like Everhart Veterinary Hospital to Microchip my pet.
Retained Deciduous Teeth:
Occasionally, the permanent adult teeth do not erupt immediately and therefore do not
force the baby teeth out which can cause crowding and future oral problems. Retained baby teeth
require anesthesia to be extracted. If your pet has retained baby teeth, we recommend having
them removed at the time of the spay/neuter appointment. The price for each extracted deciduous
tooth is $10.00.
Please Initial: _______________
Authorization and Risk Assessment:
I authorize anesthesia/surgery for my pet. The nature and risks of this procedure have been
explained to me. I understand that some risks always exist with anesthesia and/or surgery, and I
am encouraged to discuss any concerns that I have about those risks with my veterinarian before
the procedure(s) are initiated. My signature on this form indicates that any questions have been
answered to my satisfaction.
I authorize Everhart Veterinary Hospital to perform any additional diagnostic, treatment or
surgical procedure(s) deemed necessary for medical or surgical complications or otherwise
unforeseen circumstances. While Everhart Veterinary Hospital provides the highest quality of
anesthesia monitoring and surgical services, I understand that there are rare complications
associated with any anesthetic or surgical procedure. No warranty or guarantee has been given
to me as to the results or cure afforded by these treatments or procedures.
I fully understand these risks and understand that the veterinarians and hospital staff will
try to minimize such risks. I will not hold Everhart Veterinary Hospital, the veterinarians, or any
staff member liable for any complications that may rise.
I HAVE READ AND FULLY UNDERSTAND THIS SURGERY AND ANESTHESIA CONSENT FORM.
I have not given my pet any food since before 8pm on the night before the procedure, unless
otherwise advised by my doctor. I understand that this is important for anesthesia safety.

________________________________________
Signature of Pet Owner
________________
Date
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