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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