Surgical Consent Form | Advanced Animal Hospital of WI

Your Name*

First

Last

Pet's Name*

First

Last

Chart Number*

Procedure(s)*

Pre Anesthetic Exam, IV Catheter and Nail Trim

Included (charges apply)

Pre Anesthetic Blood Work (Please Check One)

Mini Chem w/ Complete Blood Count (CBC) (charges apply)
Chem 27 and Complete Blood Count (CBC) (charges apply)
Already Performed
I decline blood work and understand there are increased risks during anesthesia

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.

Dental Extractions (Please Check One)

Do NOT need to call for approval, OK to extract at doctors discretion
Please call me for approval, if I am unavailable- extract teeth at doctors discretion
Please call me for approval, if I am unavailable- DO NOT extract teeth

Please make sure to be available throughout the entire day by phone while your pet is here for a procedure.

Additional Services While Under Anesthesia

Fecal (charges apply)
Heartworm Test (charges apply)
Feline Combo (FeLV/HW) (charges apply)
Express Anal Glands (charges apply)
Microchip (charges apply)
Other

ANESTHESIA / SEDATION / PROCEDURE AUTHORIZATION

Please read and check after each statement below*

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 well being of my 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 procedure.*

I hereby authorize anesthesia/surgery for my pet. I understand that some risks always exist with anesthesia and/or surgery. By selecting this checkbox on this consent form I indicate that any questions have been answered to my satisfaction. While Advanced Animal 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 a 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 Advanced Animal Hospital, their veterinarians or any staff member liable for any complications that may arise.*

I have read and understand this authorization*

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