Anesthetic Consent Form

Owner's Name*

First

Last
Pet's Name*
Phone*
Anesthetic Consent Form for*
- Elective Procedure
- Non-Elective Procedure
Type of Procedure*
Vaccination Status*
- Current on Rabies Vaccine?
Is the pet fasted?*
- Yes
- No
I hereby certify that I am the owner of the above named pet or am responsible for it and have the authority to authorize the following procedures*
Additional Services available while you pet is sedated:*
- Ear Cleaning (Pull ear hair = $55.24)
- Dentistry (pricing varies, please ask for an estimate)
- If extraction are needed I would like you to perform any necessary extractions.
- If extraction are needed I would like you to call me before doing any extractions**
- Microchip = $57.84
- Fecal Combo (Intestinal Parasite check) = $50.00
- Express Anal Glands = $39.51
- Nail Trim = Complimentary with anesthetic procedure
**NOTE: I understand that if I am not available when I am called for authorization no extraction will be performed. I further acknowledge that this will mean my pet may have to be sedated again to have the extractions performed at an additional cost.
*
- I also authorize the use of such anesthetic, as you deem advisable, in the performance of such surgical, diagnostic procedures. I realize the administration of any anesthetic agent carries a small, but realistic, possibility of side effect that may include death.
*
- I recognize the nature of the procedure(s) being performed and realize that certain risks and complications may be involved. I acknowledge that no guarantee or assurance has been given as to the result that may be obtained.
Advances in anesthesia have made routine procedures safer, with low incidence of complications; however, occasional problems can occur due to pre-existing conditions not evident during routine histories and physical examinations.*
- I understand
In the event of an emergency I would like BFAH to:*
- Perform CPR and make every reasonable efforts to save my pets life up to (CPR ranges $300-$500)
- DO NOT RESUSCITATE
*
- I agree to hold Best Friends Animal Hospital and its Doctors and employees harmless from and against any and all liability, in the absence of negligence, for untoward anesthetic complications.
Signature*
(Please type your full name)

Days	Hours
Monday - Friday	7:30 AM – 7:00 PM
Saturday	7:30 am – 5:00 pm
Sunday	Closed

Anesthetic Consent Form

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