Anesthesia Consent Form

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Anesthesia Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Phone number where you can be reached today

Secondary emergency phone number

Sedation and general anesthesia:
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 procedure is initiated. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. While all types of anesthesia involve some risk, major side effects and complications are rare. Some risks are related to and may increase in frequency depending on the pets’ overall health, age and their unique responses to anesthetic drugs. Complications of anesthesia include but are not limited to: unexpected drug reactions, corneal ulcerations, tracheal injury, esophagitis, blood clot formation, lung injury and death.

Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me (initial one)

I authorize Crown Veterinary Dental Specialists to perform life saving treatments on my pet. This may include the administration of medications, chest compressions, oxygen, ventilation and other emergency measures deemed medically appropriate.


Pre-Anesthetic Testing

Our greatest concern is the well being of your pet. We will monitor your pet’s heart rate, respiratory rate, blood oxygen, blood pressure and EKG during surgery. This along with pre-anesthetic blood screening reduces many of the risks of surgery.
Pre-anesthetic testing provides a more complete picture of your pet’s overall health by assessing for otherwise hidden but potentially significant health issues, and helps minimize unexpected short and long term complications.
*****Pre-anesthetic bloodwork, and possibly additional diagnostics that your veterinarian has discussed with you, is mandatory for patients over 7 years of age.*****


Financial responsibility

I understand that an estimate of the costs for veterinary services will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered and during this pet’s ongoing medical treatment.
I understand that I am responsible for all costs associated with the above approved procedure. I understand that payments are due at the time of service. creditcards, CareCredit and cash are all accepted forms of payment.

Procedure authorization

My veterinarian has explained to me that while a satisfactory result is expected, all operations and procedures carry a risk of unsuccessful results, complications, injury or even death, from both known and unforeseen causes.
I understand that there is no certainty that my pet will achieve all of the expected operation or procedure benefits and no guarantee has been made regarding outcome. I have been informed of the following: • The nature and purpose of the operation or procedure, including related care, treatment and medications. • The potential benefits, risks or side effects of the operation or procedure and its recovery period • The likelihood of achieving the treatment goals • Reasonable alternatives and their relevant risks, benefits and side effects • The possible outcomes related to not receiving care or treatment. • The possibility of incurring additional costs as a result of any complications

Initial each line please:

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