Anesthetic Consent Form

South Bay Animal

Hospital & Emergency

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Anesthetic Consent Form

Please fill out this form as completely and accurately as possible.

Name *

First

Last

Phone *

Email *

Pet's Name *

At South Bay Animal Hospital & Emergency, our greatest concern is the well-being of your pet. Your pet is scheduled for an anesthetic procedure. Before putting your pet under anesthesia, we routinely perform a full physical examination. In order to maximize patient safety, we highly recommend, and sometimes require, a pre-anesthetic blood profile. The surgeon may be alerted to the presence of certain conditions that could complicate the procedure, such as dehydration, anemia, infection, diabetes, and/or kidney or liver disease. These tests are similar to what your own physician would conduct prior to you undergoing anesthesia and help ensure the administration of the most appropriate anesthetic regime. *

The Quantitative Blood Count (QBC) and Pre-Anesthetic Profile which includes: CBC (PCV (anemia), white blood cell count (infection) and red blood cell count (anemia/bleeding disorder), platelet count (clotting disorder)) and Chemistry Profile (BUN and creatinine (kidney), ALKP and ALT (liver), glucose (sugar), total protein (dehydration), and electrolytes (imbalance)).
The owner elects to decline the recommended pre-anesthetic blood tests at this time but requests that we proceed with the procedure.

Other tests are available that are not included in the above choices. The tests selected above give the doctor a suitable overview of healthy patients. For those patients who are sick or in their senior years (above the age of 9), a full senior profile can be performed the day of the procedure with the doctor’s recommendation or at the owner’s request.

Our ability to minimize anesthetic and surgical risks and maximize patient safety is greatly enhanced by the completion of a physical examination and blood work prior to a surgical procedure. If you have any questions or concerns about the scheduled procedure, please do not hesitate to call or email at 408-899-4791 / staff@sbahpr.com to discuss any aspect of the upcoming procedure.

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(s) is/are initiated. *

I have read and agree

I authorize South Bay Animal Hospital & Emergency to perform any additional diagnostic, treatment, or surgical procedures deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. I understand there are rare complications associated with any anesthetic or surgical procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks and understand the veterinarians and hospital staff will try to minimize these risks. I will not hold South Bay Animal Hospital & Emergency, the veterinarians, or any staff member liable for any complications that may arise. *

I have read and agree

Signature *

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