Anesthesia Consent Form

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Email *

Email address *

Last Name *

First Name *

Pet's Name *

Today's Date *

YYYY

I hereby authorize the following procedure(s) to be performed by the veterinarian, or veterinary staff:

Spay

Neuter

Dental

Surgery

Clear selection

I may be reached at the following phone number: *

Has your pet recently experienced any of the following conditions? *

Vomiting

Diarrhea

Coughing

Sneezing

Required

Did your pet eat this morning? *

Yes

Did your pet eat this morning? *

Yes

Would you like us to also do a complimentary nail trim on your pet while they are here today? *

Yes

Do you need us to send heartworm preventative home with your pet today? *

Yes

What heartworm preventative are you currently using?

Do you need us to send flea preventative home with your pet today? *

Yes

What flea preventative are you currently using?

If the hospital staff calls and cannot reach you by phone, please do the following: *

DO WHATEVER IS NECESSARY at this time to avoid a second anesthetic procedure for additional work

DO NOT perform any elective procedure that has not been discussed previously

In the event my pet becomes too anxious while at Harvey Animal Hospital, I authorize the recommended calming medication to be given at no charge. *

Yes

We may dispense a pain medication for your pet that requires us by the state of Michigan to get your driver's license number and date of birth. Please provide this information below.

Client Date of Birth *

YYYY

Drivers License Number *

I understand the above anesthetic, surgical, diagnostic, or therapeutic procedures may involve risk of complications, injury, or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure. Furthermore, I authorize the hospital staff in an emergency situation, to follow through with such procedures as are necessary for the wellbeing of my pet on a continuing basis until further communication with me. I agree to assume financial responsibility for all routine and emergency services rendered. By submitting this form you constitute your acknowledgment that (i) you have read and agreed to the above, (ii) the procedure(s) have been explained to your satisfaction and that you have all the information that you desire, and (iii) you authorize and consent to the performance of the procedure(s) and to the administration of anesthesia. *

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