Anesthesia Consent Form

Client’s Name

Your Email

Pet’s Name

Date

Phone Number (Where you can be reached today)

PRE-ANESTHETIC LABWORK POSTOPERATIVE PAIN MANAGEMENT MICROCHIPPING CONSENT FORM

We at Ridgetowne Animal Clinic, P.A. recommend a pre-anesthetic blood analysis to check the baseline parameters for your pet prior to an anesthetic, surgical or dental procedure.Rest assured that advances in anesthesia and surgery have made routine procedures relatively safe, with a low rate of complications.

Pre-Anesthetic Bloodwork (CBC, Chemistry) $150.00

Highly recommended for all pets. Required for pets over 7 years old

Yes

REQUIRED PAIN MEDICATION: $25.00-$50.00

Yes

PERMANENT ID MICROCHIPPING: $75.75

1st year enrollment in the National database included

Yes

For every patient in our care, we need to know, in advance, what your wishes are if your pet stops breathing and/or his/her heart stops beating. We will make every attempt to contact you right away should your pet require resuscitative efforts. Additional expenses are incurred with the attempt to resuscitate the patient.

Resuscitation - Please review and select one option below

Do Not Attempt Resuscitation (DNR): No cardiopulmonary resuscitation (CPR) efforts, only the administration of medication to help ease my pet's passing.

Cardiopulmonary Resuscitation (CPR): to attempt to restore normal heart function and breathing as deemed necessary by the doctor until I can be reached. Should my pet require cardiopulmonary resuscitation (CPR) , I request that the doctor(s) may pursue su

I, being the owner or agent of the above named pet, have the authority to grant my consent and hereby authorize the doctor(s) and technicians of Ridgetowne Animal Clinic, P.A. to perform the following procedure(s) or operation(s)

I understand that during the performance of the procedure(s) or operation(s), unforeseen conditions may be revealed that necessitates an extension of the procedure(s) or operation(s) or different procedure(s) or operation(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the exercise of the veterinarian’s judgement. I have been advised as to the nature of the procedures or operations and the risks involved. I realize the results cannot be guaranteed.

I have read and understand this authorization and consent.

Signed (Owner)

I have read and understand this authorization and consent. I, the above signed owner, certify that I am eighteen years of age or older.

Anesthesia Consent Form

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