Surgical and Anesthetic Consent Form

Patient Name*
Surgical Procedure
Date
MM slash DD slash YYYY
Phone*
*We will use this number to give updates or in the event of a crisis
What medications have been given in the last 24 hours?
Blood work: Pre-anesthetic blood work is recommended prior to any anesthetic/sedated procedure to provide vital information regarding any additional risks to your pet’s health.
- Authorize
- Decline
Pain Medication: Your pet will receive a pain injection following surgery as well as pain medication to take home. Depending on the procedure, your pet may need antibiotics as well. Pain medication and antibiotics will be administered at the sole discretion of the attending veterinarian, and will be charged to the client accordingly, this is not optional.
Please Initial Above
Recovery: It is important that your pet is kept quiet with limited activity for at least 2 weeks following their surgery. Medications can be prescribed to help keep them calm during recovery.
Calming Medications
- Authorize
- Decline
Additional Treatments: Under anesthesia is an opportune time to get your pet up to date on vaccines and to place a microchip (much larger needle best done while they’re asleep).
Vaccines
- Authorize
- Decline
Microchip
- Authorize
- Decline
Risks: The doctors and staff of Wickiup Animal Hospital will use all reasonable precautions to keep your pet safe. ALL anesthetic procedures involve some level of risk, including but not limited to hemorrhage, infection, cardiopulmonary arrest and death. I will not hold the doctors or staff responsible for any unexpected complications. If I cannot be reached at the number above, what is medically necessary for my pet will be done and I assume all risk and costs due to any complications/emergency care during the anesthetic procedure.
Initial
Authorization: I have read, understand, and agree to the above document and am the responsible party for the above pet. I am over 18 years old and have the authority to grant Wickiup Animal Hospital my consent for the procedure listed above. I understand that authorizing additional treatments/procedures will result in additional cost and payment is due at the time of services rendered.
Printed Name
Signature
Date
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

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