Anesthesia Consent Form

Obtain a pet owner's informed consent, contact details, and optional add-on service authorizations before a veterinary anesthesia procedure.

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Patient and Owner Information

Today's Date

Name of Pet

Anesthetic Procedure(s) to Be Performed

Primary Phone Number

Additional Phone Number (If I Cannot Be Reached at the Primary Number)

Email

Optional Add-On Services

Pre-Surgical Bloodwork Authorization ($93)

I authorize this pre-surgical bloodwork

Microchip Identification Authorization ($55)

I authorize the microchip implant

Post-Operative Laser Therapy Authorization ($19)

I authorize the post-operative laser therapy

Additional Procedures Request

Yes, perform additional procedures if needed

History of Seizures or Neurologic Disorder

Yes No

Do You Have Any Additional Concerns or Questions for the Anesthesia Team?

Name

First Name

Last Name

Payment and Estimate Acknowledgment

I understand and agree to the payment terms

Owner Signature and Acknowledgment of Risks

Sign here

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