Anesthesia Consent Form – Gladstone Veterinary Clinic

Name *

First

Last

Email *

Phone number where you can be reached today: *

Phone Type

Home
Cell
Work
Text Update

Secondary Phone Number *

Phone Type

Home
Cell
Work
Text Update

Pet's Name *

Procedure *

Even with the highest level of medical care, there is always some risk with any anesthetic procedure. Although complications are rare, they may include injury, illness, or even death. For this reason, we take many steps to minimize this risk for each patient:

Pre-Anesthetic Bloodwork -- allows us to diagnose medical conditions that cannot be detected on physical examination before they cause a problem under anesthesia
Thorough Pre-Anesthetic History – gives us more information to help avoid anesthetic issues
Comprehensive Physical Examination on the morning of anesthesia
Certified Veterinary Technicians – our CVTs are specially educated and trained to provide the best possible care; for your pet’s best health and safety, only CVTs or DVMs monitor anesthesia in our practice
Inhalant Anesthesia – allows your pet to sleep and wake up faster, smoother, and safer
Airway Intubation – providing a secure airway during anesthesia
Careful Monitoring – dedicated certified technician monitors heart rate, breathing rate, oxygen content in blood, blood pressure, depth of anesthesia, ECG, CO2 levels, and body temperature throughout the procedure and recovery
IV Catheter and Fluids -- allows immediate cardiovascular access in case of an emergency under anesthesia, supports blood pressure and kidney function under anesthesia, decreases nausea during the recovery period, and prevents dehydration
Temperature Support – Bair-Hugger forced air warming system
Complete Recovery – a certified technician will stay with your pet through the recovery process
Peri-Operative and Post-Surgical Pain Control – all patients will receive pain control at the doctor’s discretion, if you have difficulty giving medications by mouth please let us know before surgery

Vaccine Requirements: Dogs: distemper/parvo (DA2-P), bordetella, and rabies Cats: FVRCP, Rabies *

I have read and understand.

Dental Procedures: *

Extract hopelessly diseased teeth. I understand that this service is at an additional cost above the basic dental package.
I request a phone call to authorize any additional treatment. If I cannot be reached by phone, I understand my pet will be recovered without completing the procedure(s) and additional treatment will need to be rescheduled.

Additional procedures:

Medication needed: *

Please explain. *

CPR/DNR (select preference): Emergencies very seldom occur, but in the event of an emergency our team will make every attempt to contact you. *

Exhaust all life-saving efforts, including CPR. Necessary emergency procedures will be instituted at an additional cost.
Do not resuscitate

I realize that I am responsible for payment for the procedures and treatments I have chosen, in full, at the time of discharge. *

I have read and understand.

Signature *