Anesthesia / Procedure Consent Form in Branson, MO

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Consent for Treatment / Surgery / Anesthesia

Date of Procedure*

MM slash DD slash YYYY

Name of Owner or Authorized Agent of Patient*

Patient Name (Pet)*

The patient is presenting for the following procedure:*

I understand that the procedure requires general anesthesia and that risks and potential complications with anesthesia and surgical procedures may include, but are not limited to:

Adverse reactions to anesthetic agents, organ failure (heart, liver, kidney), obstructive airway, regurgitation, aspiration of vomitus, gastric dilation-volvulus (GDV), nerve damage, prolonged anesthetic recovery and temporary dysphonia, post-operative infection, equipment malfunction, and death.

I have been informed that every precaution will be taken to minimize these risks, but no surgical or anesthetic procedure is without some risk, and outcomes cannot be guaranteed.

Contact Information

The primary contact person to be reached during and after the procedure:*

The best phone number to reach the primary contact during and after the procedure:*

Feeding & Treatments Prior to Anesthesia

See our instructions prior to anesthesia.

Many long-term oral medications can be given as usual prior to anesthesia with 1–2 tablespoons of canned food or coated with pill-wrap paste.

Medications that can be continued on schedule:
thyroid medication (Thyro-Tabs, methimazole), behavior medications, pain medications (tramadol, gabapentin), anxiety medications, heart medications (Vetmedin, Salix/furosemide), antibiotics, steroids.

Some medications should be discontinued the day before anesthesia:
blood pressure medications (amlodipine, enalapril, benazepril, telmisartan).

Diabetic pets:
Please give ½ the usual dose of insulin 2–4 hours prior to drop-off.

Please call us to verify your pet’s individual medication instructions if you are unsure!

What time will the patient last eat prior to anesthesia?*

What will the patient last eat prior to anesthesia?*

List all current medications and supplements and date and time last dose will be given:*

Is the patient presenting for Ovariohysterectomy (Spay) Surgery?*

Yes

If the patient is to be spayed, when was the last heat cycle?*

Cardiopulmonary Resuscitation (CPR)

This Cardiopulmonary Resuscitation (CPR) Consent Waiver outlines your options and the associated financial implications regarding CPR treatment in the event of the patient’s cardiac or respiratory arrest during hospitalization. Please carefully review the following options and select your preferred course of action.*

OPTION 1: I hereby grant the attending veterinarian the exclusive discretion to make all decisions regarding CPR in the event of the patient’s cardiac or respiratory arrest during hospitalization. I fully acknowledge and understand that CPR may incur associated medical expenses. I accept full financial responsibility for these expenses, which shall not be less than $325. ____________________________________________________________________________________________________________________

OPTION 2: I hereby grant my consent to the initiation of CPR in the event that the patient experiences cardiac or respiratory arrest during their hospitalization. I expressly request to be contacted immediately upon the occurrence of such an arrest to be informed of the patient's condition and to provide authorization for the continuation of CPR efforts. I consent to the continuation of CPR until I am successfully reached. However, if I cannot be reached within 15 minutes of the commencement of CPR, I relinquish all decision-making authority regarding CPR to the attending veterinarian. I fully acknowledge and understand that CPR may incur associated medical expenses. I accept full financial responsibility for these expenses, which shall not be less than $325. ____________________________________________________________________________________________________________________

OPTION 3: I hereby decline CPR and elect a "Do Not Resuscitate" (DNR) status in the event of the patient’s cardiac or respiratory arrest during hospitalization. I understand that this decision means that CPR will not be performed, and I accept the consequences of this choice.

Pre-Anesthetic Testing

Pre-Anesthetic Blood Screen*

1. Within the last 4 weeks, my pet had blood work finding normal or stable blood cell counts, blood sugar, kidney health, and liver health.

2. I consent to a Pre-Anesthetic Blood Screen for my pet and accept full financial responsibility.

3. I do not consent to a Pre-Anesthetic Blood Screen and acknowledge that I am fully aware of the possible consequences of anesthesia and surgery being performed without the knowledge obtained from the aforementioned blood screen.

Pre-Anesthetic Blood Screening is done to detect hidden illnesses and inform us of potential complications from anesthesia. This screen includes a 7-point chemistry panel and a complete blood count.

Pre-Anesthetic Electrocardiogram (ECG)*

1. I consent to a Pre-Anesthetic ECG for my pet and accept full financial responsibility. ($39.99)

2. I do NOT consent to a Pre-Anesthetic ECG. If one is not performed, I acknowledge that I am fully aware of the possible consequences of anesthesia and surgery being performed without the knowledge obtained from the aforementioned ECG.

An electrocardiogram (ECG) is performed to assess heart rhythm, detect underlying heart conditions, and guide safe anesthetic protocols, especially before surgery or in pets with heart-related concerns. Cardiologists have found that about 1 in 25 pets may have a heart rhythm issue that can’t be detected by listening with a stethoscope.

Is Patient presenting for a professional dental procedure?*

Yes

If your pet is presenting for a professional dental procedure with general anesthesia...

Risks and potential complications with anesthesia and dental procedures may include, but are not limited to:

Adverse reactions to anesthetic agents, organ failure (heart, liver, kidney), obstructive airway, regurgitation, aspiration of vomitus, gastric dilation-volvulus (GDV), nerve damage, prolonged anesthetic recovery and temporary dysphonia, post-operative infection, equipment malfunction, and death.
Specific complications for dentistry include: oral infections, extraction site dehiscence, bleeding from the mouth and nares, corneal ulcers, and mandibular fractures.

Our anesthetized dental evaluation and cleaning include anesthetized oral exam and x-rays of each tooth. Sometimes additional dental treatments beyond routine scaling and polishing are indicated based on these findings. Please expect a phone call during your pet's procedure to discuss any additional indicated treatments. In the event we are unable to reach you by phone during the procedure, you have the option to consent to the treatment of dental disease including, but not limited to the following:

Oral surgery/extractions including local oral nerve block(s), use of sterilized extractions packs, post-operative oral x-rays, and post-extraction laser therapy to reduce pain and inflammation
Enamel bonded sealant application
Periodontal disease treatment
Post-procedure pain management

Options:*

OPTION 1: If I’m unable to be reached by phone during the procedure, I consent to additional indicated treatment of dental disease detected during the procedure and I accept full financial responsibility.

OPTION 2: If I’m unable to be reached by phone during the procedure, I prefer to defer additional indicated treatment of dental disease until a later anesthetized follow-up procedure.

Microchip

Microchip*

1. My pet is already microchipped.

2. I would like my pet to be microchipped and registered during the procedure and I accept full financial responsibility.

3. I do NOT want my pet to be microchipped during the procedure.

By digitally signing and clicking submit, I confirm that I am the owner or authorized agent of the patient named above. I am at least 18 years old. I understand that the procedure, its possible outcomes, and the associated risks have been fully explained to me. I have had the opportunity to ask questions and discuss any concerns I had. I also recognize that, as with any medical procedure, results cannot be guaranteed. Having read and understood this authorization, I hereby accept and agree to the terms of this consent form and accept full financial responsibility for the procedure.

Name of Owner or Authorized Agent*

Today's Date*