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Hours 3970 Douglas Blvd
Roseville, CA 95661

Anesthesia Consent Form

Pet Name:*

Please answer the following questions as they relate to what anesthetics are given to your pet:

Your pet is scheduled for a procedure that requires general anesthesia. We are quite proud of our "safe" anesthesia record here, but as you know we CANNOT guarantee 100% safe anesthesia every time. We wish to minimize any unknown risk factors that may not be evident physically. All of our patients will have a pre-anesthetic blood panel on the day of surgery or a few days before surgery. It is important to know about liver and kidney functions prior to administering anesthetic drugs. The body processes and eliminates anesthetic drugs using these organs, and if these organs are not functioning 100%, your doctor can adjust the anesthetic agents accordingly, decreasing the risk to your pet. Should there be any indication that an abnormality exists, the doctor will either contact you before proceeding or take the necessary steps to help ensure the safety of your pet. We will also place an intravenous catheter in their leg to provide fluids during anesthesia.

To your knowledge, has your pet ever had any seizures or convulsions?*

Yes

No

Has your pet ever had trouble with anesthesia?*

Yes

No

Has your pet been given any ASPIRIN within the last week?*

Yes

No

If your pet is overweight/obese or in heat at the time of spay or neuter there may be additional charges.

To identify your pet has been altered, there will be a tattoo at the incision site.

Your pet will be given one dose of an injectable pain medication either prior to or post surgery. This cost is included in the price of the spay or neuter.

Your pet may need additional pain medication or sedatives to be sent home.

I am the owner or agent for the owner of the above pet and have the authority to execute this consent. I hereby consent and authorize Douglas Blvd Veterinary Clinic to perform the following procedures:*

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. Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff has my permission to provide such treatment and I agree to pay for such services (cost can build quickly).*

Yes

No

I understand that during the procedure, unforeseen conditions may be revealed that necessitate an extension of the forgoing procedure. Therefore, I hereby consent to and authorize the performance of such procedures and or surgery as are necessary and desirable in the exercise of the veterinarian's professional judgement. I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed by the veterinarian.

Signature*

Douglas Boulevard Veterinary Clinic