Surgery/Anesthesia Consent

Your Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Patient Information
Name*
Surgical Procedure(s) to be performed*
Do you have an e-collar at home?*
- Yes
- No
For medications, do you prefer liquid or tablet or Either is fine?*
- Liquid
- Tablet
- Either
IMPORTANT REMINDER: NO FOOD AFTER 9PM ON THE NIGHT BEFORE SURGERY DAY. Water is ok to give.*
- I Understand

Current Medications*

Medication	Last Given / Will give prior to surgery (date & time)

Click “+” icon to the right to add more medications.

Please Read Carefully
I, the undersigned owner or agent of the pet identified above, authorize the staff of Better Health Animal Hospital to perform the above procedure(s)*
- I authorize
While Better Health Animal Hospital provides the highest quality of anesthesia monitoring and surgical services, I understand that there are still risks and potential complications associated with anesthesia, sedation, and/or surgical procedures, including but not limited to respiratory depression, cardiovascular complications, allergic reactions, prolonged recovery or agitation, and very rarely, even death. I understand that the attending veterinarian and hospital staff will do everything possible to reduce any risks and complications. I will not hold Better Health Animal Hospital, the veterinarian or any team member liable for any unforeseen complications and/or death that may arise after surgery.*
- I understand
During the course of your pet’s examination, anesthesia, surgical, or dental procedure, the veterinarian may determine that it would be in the best interest of my pet to perform additional procedures beyond what was initially presented in the estimate (i.e additional tooth extractions, unexpected mass removals and biopsy, antibiotic treatment, etc). I understand the veterinarian would always prefer to contact me prior to proceeding, but in some instances I may not be available at the time that the anesthetic procedure is being performed on my pet. My preferences are as follows: (Choose One)*
- I trust your judgment. Please proceed what is necessary in the best interest of my pet
- DO NOT perform any additional procedures on my pet without contacting me first and receiving my consent. I understand that failure to perform recommended procedures under today’s anesthesia may require another anesthetic procedure at a later date
IN CASE OF AN EMERGENCY
In the event of an emergency, I authorize the attending veterinarian to administer necessary treatments, including but not limited to CPR (Cardiopulmonary Resuscitation), additional medications, or other life-saving measures. I understand that additional costs may be incurred.
CPR Preference (choose one):
- I request CPR be performed in case of an emergency (additional charges apply).
- I do not wish for CPR to be performed; I prefer Do Not Resuscitate (DNR).
Financial Responsibility:*
- I understand that the estimated cost for anesthesia and associated procedures has been provided to me and that payment is due at the time of service. I accept full financial responsibility for all treatments provided.
Signature*
Date*
MM slash DD slash YYYY

Patient Information

Please Read Carefully

IN CASE OF AN EMERGENCY