Surgical Consent Form
Owner’s Name: _________________________________
Animal: _________________________
Address: _______________________________________
Species: _________________________
________________________________________
Breed: __________________________
Account Number: __________________________
Sex: ____________________________
I am the owner or agent for the owner of the above-described animal and have the authority to execute this consent.
I hereby consent and authorize the performance of the following procedure(s) or operation(s).
______________________________________________________________________
I understand that during the performance of the foregoing procedure(s) or operation(s), conditions may be revealed that
necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) or operation(s) than those set
forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are
necessary and desirable in the exercise of the veterinarian’s professional judgment.
I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel
will be employed as deemed necessary by the veterinarian.
I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I realize that results cannot be
guaranteed.
I have read and understand this authorization and consent.
_______________
Date
_______________________________
Signature of Owner/Agent
____________________________________
Witness to Signature
Pre-Anesthetic Blood Testing
Your pet is with us today for a procedure that will require anesthesia. As part of our commitment to provide the safest care
for your pet that we can during its visit, we will perform a complete physical examination prior to anesthesia.
The successful use of anesthetics always depends on the normal function of the vital organs (kidneys, liver, heart). Proper
liver and kidney function are imperative for your pet to metabolize the anesthetic agents. The liver must change the
anesthetic into new chemical compounds, which the kidneys will then excrete into the urine. Failure of either of these
functions may lead to prolonged anesthetic recovery and possibly, in extreme instances, death. It is for this reason that we
strongly recommend a pre-anesthetic blood screen be performed. Abnormalities in liver or kidney functions may preclude
the surgery altogether or more commonly allow the veterinarian to change the amount or type of anesthetic before proceeding
with the procedure.
Our laboratory is fully equipped and staffed to perform these important blood tests. Results will be immediately available to
be examined before anesthesia. Please indicate at the bottom of the anesthesia consent form whether you wish for the preanesthetic blood screen to be performed.
If your pet is older or had any other pre-existing medical conditions, further testing may be advisable. Please ask the
veterinarian for more information if these conditions apply.
Accept _______________________________
Decline __________________________