Anesthesia Surgical Consent Form
Please fill out this form prior to your pet's procedure.
Email address *
Client Name: *
Patient Name: *
Best phone number to call the day of procedure: *
Does your pet have a current rabies vaccine? A current rabies vaccine certificate is required or CAHW will rabies vaccinate my pet at a $15.00 additional charge *
If yes, where and when did your pet receive the rabies vaccine? List clinic below. Leave blank if it was given by CAHW.
Is your pet on any medications?(other than heartworm and flea prevention) *
If yes, please list the medications below and when last given.
If fleas are present on your pet today, a Capstar (24 hour medication to kill fleas) will be administered at a $8.99 additional charge. *
We can administer a 30 day flea & tick prevention for additional costs if you prefer (Please ask for details)
A complete physical exam will be performed on your pet prior to the surgical procedure. However, this may not identify all systemic or metabolic problems. For this reason, we recommend your pet have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia. *
I, the undersigned owner or agent of the pet identified above, certify that I am eighteen years of age or over and authorize the staff/veterinarians of Companion Animal Hospital of Waller to perform the above procedure(s) and understand that I am responsible for all charges related to this patient. *
In the case that your pet were to suffer cardiac and/or pulmonary arrest (heart or breathing stops), do you authorize us to provide life-saving measures (i.e. cardiopulmonary resuscitation)? Costs of these services can be between $200-$500. If you choose to allow these procedures for your pet, we will try and contact you as soon as possible to inform you of the situation and discuss the options of how to proceed. *
Have you received an estimate for the procedure to be performed? *
If no, would you like to be provided with an estimate?
Clear selection
I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. *
Companion Animal Hospital of Waller recommends that all patients be microchipped for identification to aid in the recovery of a lost pet. Would you like to have your pet microchipped for an additional charge of $45? *
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. *
I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. *
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