Anesthesia & Surgery Consent Form

Admission, anesthesia & procedure authorization

01

Client & patient

02

Procedure

03

Today’s check-in

04

Anesthetic & surgical risks

I understand that sedation, general anesthesia, and surgery carry risks, even in healthy animals. Rare but serious complications can include adverse drug reactions, aspiration, abnormal heart rhythms, and, in rare cases, death. Surgical risks include bleeding, infection, and wound complications. Pre-anesthetic screening and monitoring reduce these risks but cannot remove them.

Pre-anesthetic bloodwork
IV catheter & fluids
Resuscitation status
Optional services while under anesthesia
Anesthesia & Surgery Consent Form continued
05

If additional problems are found

06

Acknowledgments

Please initial each statement
  1. The procedure, its risks, and the alternatives have been explained to me, and my questions were answered.
  2. I have received an estimate, and I understand the final cost may differ if the plan changes.
  3. I agree to pay for services provided, including any deposit required at admission.
  4. I am the owner of this animal or am authorized to make medical decisions for it.
✕
Owner / authorized agent signature
✕
Staff witness signature
07

Admission checks

Staff use
Belongings left with patient