Anesthesia/Surgery Consent Form – Gateway Companion Animal Clinic

Pet Info

Name*

Age (approx)*

Species

Feline
Canine

Sex*

Neutered Male
Intact Male
Spayed Female
Intact Female

Breed*

Color*

Rabies*

Yes
No

Microchipped*

Yes
No

ID

Owner Info

Name*

First Last

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Surgery Request

Form Consent*

I, the pet owner, or agent thereof, confirms that all of the information on this form is accurate and true to the best of my knowledge.

I, the undersigned owner or agent of the pet identified above, certify that I am eighteen years of age or over and authorize the veterinarians at Gateway Companion Animal Clinic to perform the above procedures. I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedures are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

- The reasonable medical and/or surgical treatment options for my pet
- Sufficient details of the procedures to understand what will be performed
- How fully my pet will recover and how long it will take
- The most common and serious complications
- The length and type of follow-up care and home restraint required
-The estimate of the fees for all services
- Any necessary payment arrangements

Pre-anesthetic bloodwork*

Yes - I would like to have pre-anesthetic bloodwork completed in an effort to ensure my pet doesn't have any pre-existing health problems that might adversely effect the anesthesia.
No - I do not wish to have any blood work performed on my pet prior to anesthesia.

In effort to provide the best care available for your pet, we offer pre-anesthetic blood work to help ensure your loved one will not have any adverse effects from the anesthetic. All animals will benefit from the blood work, but we strongly urge all large breed dogs over 5 years of age and all small breed dogs and all cats over 7 years of age have blood work performed prior to any anesthetic procedure.

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay a deposit of % of the estimated fees, assume financial responsibility for the remaining fees, and provide payment via cash, credit card, or debit at the time my pet is discharged from the hospital.*

Life-saving emergency*

Has my permission to provide such treatment and I agree to pay for such services.
Does not have my permission to provide such treatment and I do not agree to pay for such services.

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff.

Today's Date*

Digital Signature (Type your name)*

Surgical Consent Form

Pet Info

Owner Info

Surgery Request

We have made veterinary medicine our life work because we love and respect the animals entrusted to our care.