Anesthetic Consent Form

(Fill out 1 form for each patient)

Client Name :*

Patient Name :

Phone Numbers (Please provide only numbers where you can be reached day of procedure)

Primary :

Secondary :

Procedure Planned :

Today your pet is scheduled to undergo a medical procedure requiring the administration of anesthetic agents. We at Encanto Pet Clinic will perform this procedure with all reasonable care and precautions.

To better ensure your pet’s safety and ability to tolerate anesthesia, we require a pre-anesthetic blood screening which does a complete blood count to check your pets blood clotting capability, assess adequate oxygen carrying capacity, electrolytes, and assess proper liver and kidney function, which is how your pet will metabolize the anesthetic after surgery. The fee for this pre-anesthetic blood screen is $82.80.

I have read and agree to the screening

In addition, we also offer a pre-operative electrocardiac (ECG) evaluation. This service evaluates the electrical conduction of the heart and looks for any arrhythmias.

The fee for the pre-operative evaluation is $34.60.

I request the Pre-Operative ECG
I decline the Pre-Operative ECG
I would like the choice to be at the doctor’s discretion

Are there any other treatment or procedures you would like your pet to have today? (services requested will incur additional fees)

Vaccines
Nail Trim
Home Again Microchip
Heartworm Test
Felv/FIV test
Fecal Check
Urine Check
OraVet Sealant
Check Ears

I have read and understand the preceding information, and agree to the indicated procedures.

Signature of responsible agent

Date

We are not a 24 hour clinic, therefore trained personnel are not on premises after business hours.

Name

This field is for validation purposes and should be left unchanged.