All pets need a 12 hour fast prior to undergoing anesthesia. 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 *

Pet's Name *

Date of Appointment

Is your pet currently on medication?

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.

Dental Extractions

Diseased teeth may need to be extracted, as they are painful to the animal and create infections in the mouth. Depending on the severity and mobility of the diseased tooth, they may be required to be extracted surgically.

Please Choose One *

I consent to non-surgical extractions at veterinarian’s discretion.
I consent to surgical extractions at veterinarian’s discretion.
I would like a phone call prior to any extractions.

I understand that unforeseen conditions may be revealed during the procedures that may require more extensive or different treatments.

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. *

Yes

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 performed 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 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 procedure 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. (note that some procedures require a later time) *

Date

Time

Client Forms

Dental Consent Form