Anesthesia Consent Form

Client Name

First Last

Patient Name

First Last

Phone Number

Alternate Phone

Would you like for us to text or call?

Text

Call

Anesthetic/Surgical procedures to be performed:

Pre-Anesthetic Blood Testing(Required)

It is important to understand that a pre-anesthetic profile does not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future.

Our greatest concern is the well-being of your pet. We will perform a physical examination before administering anesthesia. However, disorders of the liver, kidneys or blood, are not detected unless blood testing is done.

Abnormalities of any of these may increase anesthetic risk. For these reasons we highly recommend pre-anesthetic blood screens.

Yes, I want the pre-anesthetic blood work.

I decline the recommended pre-anesthetic blood-work and understand the surgical risks.

Microchip

I authorize the doctor to microchip my pet while under anesthesia.

Authorization to Perform Surgical Procedure and/or Treatments

I, the undersigned owner or owner's agent, of the pet mentioned above the hereby authorize the doctors at Wake Vet Hospital & Urgent Care to perform the above anesthetic and surgical procedure(s) for my pet. I understand that some risk always exists with anesthesia and/or surgery, and that I am encouraged to discuss any concerns about those risks with the attending veterinarian before the procedure(s) is/are initiated.

Electronic Signature(Required)

Date(Required)

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Wake Veterinary Medical Center

1007 Tandal Place
Knightdale, NC 27545
Phone: (919) 266-9852
Fax: (919) 217-0314
Email: [email protected]

OPEN 24 HOURS EVERY DAY

For after hours emergencies, please call (919) 266-9852.