All pets need a 12 hour fast prior to surgery. Please do not feed your pet breakfast the day of the procedure.

Client Name *

First

Last

What is the best phone number to reach you at today? *

Email *

Patient Name *

Date of Appointment

Is your pet on any current medications?

No
Yes - please notify the CVT or veterinarian

Pre-Anesthetic Blood Work

Pre-anesthetic blood work checks internal organ functions and is a vital part of safe anesthesia. Help us provide the best level of care for your pet by choosing to perform blood work prior to anesthesia or sedation.

Please Choose One *

Chem 10: Basic internal organ screen (liver, kidneys) For generally healthy, younger patients. ($119.75)
Chem 17: Full blood work an all major organs and electrolytes. Recommended in geriatric patients. ($223.00)
I decline blood work and understand there are increased risks during anesthesia.

Intravenous (IV) Fluid Support During Anesthesia

IV Catheter placement and administration of IV fluids during anesthesia helps maintain blood flow to the organs and keeps blood pressure normal. IV fluid support greatly increases the safety of anesthesia.

*Please note some procedures and conditions will need additional IV fluid support for longer periods of time which will be at additional cost. Your pet’s veterinarian may require IV fluids for anesthesia (most commonly in geriatric patients or debilitated patients).

Please Choose One *

Administration of IV fluids during anesthesia- covers fluids and IV pump use for short procedures. ($97.00)
IV catheter placement WITHOUT fluid therapy- we will place an IV catheter to administer anesthetic medications and for emergency IV access only. ($44.83)
I decline IV fluids.

Laser Procedures (Spay, Neuter, Mass Removal, etc.)

The benefits of laser include: decreased pain and reduced bleeding/blood loss. *This is an additional cost- ranging from $84 to $460. Please call if you wish to know the specific amount based on the procedure being performed.*

Please Choose One *

I would like the use of the laser for this procedure.
I decline the use of the laser.

I understand that unforeseen conditions may be revealed during the procedures that may require more extensive or different treatments. I understand that all reasonable efforts will be made to contact me to authorize any additional treatments. However, if these efforts are unsuccessful, I authorize the performance of any procedures or treatments that are deemed immediately necessary for the health and wellbeing of my pet in the professional opinion of the attending veterinarian.

I understand that I assume financial responsibility for all services rendered.

The veterinarian has described the procedures identified in the consent form and has explained to my satisfaction the purpose for performing them and the risks involved with them. I realize that there can be no guarantee as to the outcome of any procedures.

I hereby authorize anesthesia/surgery for my pet. I understand that some risks always exist with anesthesia and/or surgery. My signature on this consent form indicates that any questions have been answered to my satisfaction. While KM Regional Veterinary Hospital provides the highest quality of anesthesia monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical procedure. In particular, I have been advised that there is an extremely small risk of death, complications, or side effects every time an anesthetic is used and that I have been advised of the possibility. I acknowledge these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I will not hold KM Regional Veterinary Hospital, the veterinarians, or any staff member liable for any complications that may arise.

I have read and understand this authorization. *

An estimate will be gone over with you before the procedure. Please be aware that the final invoice must be paid in full on the day of service. *

I understand

Please choose one of the following *

I wish the staff of KM Regional Veterinary Hospital to perform CPR (resuscitation) on my pet if my pet suffers respiratory or cardiac arrest. I understand that my pet may respond initially and then suffer another arrest later. I understand that my pet may die despite CPR. I understand that if my pet survives because of CPR, they may have brain damage. The estimate for initial CPR is $300-$500.
I do NOT want CPR preformed on my pet. I understand that if my pet stops breathing and/or their heart stops beating that my pet will die unless CPR is preformed. I elect to DNR (do not resuscitate) and would like this entered in my pets chart.

Signature *

Clear Signature

Date *

Do we have your permission to post any pictures we take of your pet on our professional social media outlets? We will not post any personal information or offensive material. *

Yes please!
No thank you.

We will touch base with you after the surgery is done and your pet is awake from anesthesia. What form of communication would you prefer?

Phone Call
Text Message
Email

Please select a desired Go-Home time for after surgery. (Note that more involved procedures may require a later time) *

Date

Time

Client Forms

Anesthesia Consent Form