Anesthesia Consent Form

Client's Name*
First Last
Email*
Phone*
Pet's Name*
Pre-Anesthetic Blood Work

Pre-anesthetic blood work checks the internal organs and blood count 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.
Pre-Anesthetic Blood Work*
- Prep Profile (Pre-anesthetic profile) $90.05 - Basic internal organ screen (liver, kidneys) For generally healthy, younger patients.
- Full Blood Chemistry $170.30 Full blood work an all major organs and electrolytes. Recommended in geriatric patients.
- I decline blood work and understand there are increased risks during anesthesia.
(PLEASE CHECK ONE )
Intravenous (IV) Fluid Support During Anesthesia

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 doctor may require IV fluids for anesthesia (most commonly in geriatric patients or debilitated patients).
Intravenous (IV) Fluid Support During Anesthesia*
- Administration of IV fluids during anesthesia (covers fluids and IV pump use for short procedures). $65.65
- I decline IV fluids.
(PLEASE CHECK ONE )
PLEASE MAKE A SELECTION:*
- Dental Consent Form
- Surgical Consent Form

DENTAL CONSENT FORM
Dental X-rays

This detects abnormalities of the tooth that exist below the gum line.
Dental X-rays*
- I would like full mouth dental x-rays. $90.75
- I decline dental x-rays at this time
(PLEASE CHECK ONE)
Dental Extractions*
- I consent to non-surgical and surgical extractions at doctor’s discretion.
- I would like a phone call prior to any extractions.
What number shall we call?*

SURGERY CONSENT FORM
Laser Procedures (Spay, Neuter, Mass Removal, etc.)
- The benefits of laser include: decreased pain, reduced bleeding/blood loss, faster healing time and reduced risk of infection.
- I decline the use of the laser.
*Please note some procedures and conditions require 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.
Owner Signature
Today's Date:
Date Format: MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

CLIENT PORTAL

Step 1 of 4

Pre-Anesthetic Blood Work

Intravenous (IV) Fluid Support During Anesthesia

DENTAL CONSENT FORM

Dental X-rays

SURGERY CONSENT FORM