Anesthesia Consent Form:
Owner/Owner Agent: ______________________________
Address: ______________________________
Phone Number: ______________________________
Emergency Contact: ______________________________
Patient’s Name: ______________________________
Species: ____________Sex:_____________
Breed: __________ Age (D.O.B.) ________
As the owner or owner’s agent of the above patient, I understand I am authorizing and give consent to the on
staff Veterinarian to perform the following procedure(s):
____________________________________________________________________________
Initial one of the following:
General Anesthesia ________
Sedation ________
Advances in anesthesia and surgery have made routine procedures performed under the current updated
standards of care for anesthesia very safe, with a low risk of complications. Nevertheless, occasional problems
can arise due to preexisting conditions not evident during pre-anesthetic examinations.
Pre-anesthetic lab work is recommended for ALL pets undergoing general anesthesia. Pre-anesthetic lab work
can help minimize the risk of complications arising under anesthesia from medical conditions not evident
during a pre-anesthetic examination. Pre-anesthetic lab work is required for pets 7 years and older
undergoing general anesthesia or sedation, and may be required if your pet is having an involved,
complicated or prolonged procedure.
Please initial which blood work panel you would like to have done for your pet:
________ ($85.00) - ($76.50 w/Discount) Pre-anesthetic panel including 10 Chemistry Function Parameters and
a Complete Blood Count is recommended for apparently healthy pets under the age of 7 years.
________ ($150.00) - (135.00 w/ Discount) Comprehensive Health Panel including 17 Chemistry Function
Parameters, Complete Blood
Count and Electrolytes is available for older pets or pets undergoing
prolonged procedures.
________ NO, I DECLINE pre-anesthetic lab work as recommended by Liberty Veterinary Medical Center.
Please select any additional services you would performed for your pet:
________ Anal Gland Expression $20.79 (18.71 w/Discount)
________ Microchip $57.75 (51.98 w/Discount)
________ Ear Cleaning/Flushing $17-34 (15.5-31.00 w/ Discount) ________ Nail Trim $17.32 (15.59 w Discount)
I authorize the above procedure(s) to be performed on my pet today, I understand that during or after the
performance of these procedures, there is a risk that unforeseen conditions may arise resulting in anesthetic
and/or surgical complications or death. I acknowledge the procedures have been explained to me, and agree
to hold harmless the staff of Liberty Veterinary Medical Center for any such complications. I am also aware
that arising complications will not relieve my financial obligation for any and all costs incurred for
emergency procedure performed in the event complications may arise.
______________________________________
(Please Sign & Date)
****ALL ANIMALS MUST BE CURRENT ON RABIES VACCINE AND FREE OF EXTERNAL PARASITES. ANY
PATIENT FOUND TO HAVE PARASITES, INCLUDING FLEAS, WILL BE TREATED AT THE OWNERS EXPENSE.
Additional recommendations to make your pet more comfortable after surgery:
We recommend an additional non-steroidal anti-inflammatory injection (Rimadyl or Metacam) for additional
pain management post operatively. Your pet will receive pain medication either pre or post operatively as
part of our anesthetic protocol. The above recommended NSAID injection is in addition to routinely given
pain medication to make your pet more comfortable. The decision to give these medications and will be made
based on pre-operative lab work results, age, condition, and concurrent use of other medications by the
veterinarian performing your pet’s surgery.
We also offer an anti-nausea injection (Cerenia) to prevent nausea and vomiting often resulting from
narcotics and anesthesia. Recent studies have shown faster recovery and return to normal eating habits in
pets receiving this injection prior to surgery.
Rimadyl & Cerenia Dose Charts
Rimadyl or Metacam
Cerenia
5-10 lbs
$40-40
2.2-10 lbs
$40-40
11-20 lbs
$40-40
11.1-33 lbs
$40-40
21-40 lbs
$40-40
33.1-66 lbs
$44.5-62
41-60 lbs
$40-50
66.1-88 lbs
$79
61-80lbs
$48-61
88.1-110lbs
$96
Over 80 lbs
$61-$74
110.0-132lbs
$113.5
Please initial the following below:
________ I would like the additional NSAID injection to be given to my pet based on conditions stated above.
________ NO, I DECLINE the additional NSAID injection to be given to my pet.
________ I would like the additional anti-nausea injection (Cerenia) to be given to my pet.
________ NO, I DECLINE the additional anti-nausea injection (Cerenia) to be given to my pet.