Anesthesia Consent Form in Houston, TX | Memorial Veterinary Clinic

Client Name*
First Last
Patient Name*
First Last
Phone number at which owner can be reached today or tomorrow:*
Additional number*
Would you like us to text you after the procedure, or would you prefer a call?
- Text
- Call
Would you like us to text you after the procedure, or would you prefer a call?*
Is your pet having a dental procedure?
- Yes
- No
Do you want to be called if there will be tooth extractions?
- Yes
- No
if yes in the event that I cannot be reached, I give permission to proceed with extractions deemed as medically necessary by the doctor
- Yes
- No
I, the undersigned owner or agent of the pet identified above, hereby request and authorize the staff of Memorial Veterinary Clinic to perform the above procedure(s). I consent to and authorize the performance ofsuch as necessary in the veterinarian’s professional judgment.
*
- I have read and agree
Microchip: *There is an additional fee for this procedure*
- Yes
- No
- Already has one
Have you given your pets any medications or supplements in the past week?
- Yes
- No
Other medication
When was the last time fed?
Any other concerns/allergies/procedures?
I understand that I will be speaking with a nurse prior to dropping off my pet at Memorial Veterinary Clinic,which can take up to ten minutes. I understand that there is a scheduled drop off and pick up time.*
I understand that I will be speaking with a nurse prior to dropping off my pet at Memorial Veterinary Clinic,which can take up to ten minutes. I understand that there is a scheduled drop off and pick up time.
- I have read and agree
I authorize the Veterinarian to administer anesthesia and pain relief medication as needed before and/or after the procedure. I understand that there are risks associated with the use of any medication. I also understand that there are certain risks and complications associated with any operation or procedure of this type, including death of my feline(s) or canine(s). I acknowledge that I have had the opportunity to speak with a Memorial Veterinary Clinic licensed veterinarian about the risks and complications associated with the above listed procedure(s). *
I authorize the Veterinarian to administer anesthesia and pain relief medication as needed before and/or after the procedure. I understand that there are risks associated with the use of any medication. I also understand that there are certain risks and complications associated with any operation or procedure of this type, including death of my feline(s) or canine(s). I acknowledge that I have had the opportunity to speak with a Memorial Veterinary Clinic licensed veterinarian about the risks and complications associated with the above listed procedure(s). *
- I have read and agree
Memorial Veterinary Clinic strives to practice high quality medicine at all times. All patients will receive a thorough physical examination before anesthesia. We use the safest anesthesia available, however to further minimize risk during anesthesia we will perform pre-anesthetic labwork, place an intravenous (IV) catheter, and administer IV fluids on all procedures. This screening is similar to those used in the human hospitals, and is used to ensure that your pet has no hidden medical problems not detectable on the physical examination. The tests we run include a CBC (complete blood count) and chemistry profile (internal organ function)if not already completed in the last thirty days.
Memorial Veterinary Clinic strives to practice high quality medicine at all times. All patients will receive a thorough physical examination before anesthesia. We use the safest anesthesia available, however to further minimize risk during anesthesia we will perform pre-anesthetic labwork, place an intravenous (IV) catheter, and administer IV fluids on all procedures. This screening is similar to those used in the human hospitals, and is used to ensure that your pet has no hidden medical problems not detectable on the physical examination. The tests we run include a CBC (complete blood count) and chemistry profile (internal organ function)if not already completed in the last thirty days.
- I have read and agree
I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, I agree that the Veterinarian may perform emergency life-saving procedures including surgery if complications arise and the Veterinarian deems it medically necessary. *
I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, I agree that the Veterinarian may perform emergency life-saving procedures including surgery if complications arise and the Veterinarian deems it medically necessary. *
- I give my permission [yes]
- I do not give my permission [no]
I understand that per clinic policy my animal(s) must be current on rabies vaccine, distemper, adenovirus 2, parvovirus and parainfluenza vaccine (for canines only), a feline viral rhinotracheitis, calicivirus and panleukopenia vaccine (for felines only). Vaccination services may be waived only if current vaccine proof is received at the time of check in, or at the discretion of the veterinarian on a case by case basis.
I understand that per clinic policy my animal(s) must be current on rabies vaccine, distemper, adenovirus 2, parvovirus and parainfluenza vaccine (for canines only), a feline viral rhinotracheitis, calicivirus and panleukopenia vaccine (for felines only). Vaccination services may be waived only if current vaccine proof is received at the time of check in, or at the discretion of the veterinarian on a case by case basis.
- I have read and agree
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, Iunderstand that no guarantee or warranty has been made regarding the results that may be achieved. I alsoassume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. Though complications can occur naturally on rare occasions, they are much more likely to occur when there is a failure to comply with post-operative instructions sent home on the day of surgery. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. **
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, Iunderstand that no guarantee or warranty has been made regarding the results that may be achieved. I alsoassume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. Though complications can occur naturally on rare occasions, they are much more likely to occur when there is a failure to comply with post-operative instructions sent home on the day of surgery. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *
- I have read and agree
I RELEASE MEMORIAL VETERINARY CLINIC, VETERINARIAN, VETERINARY TECHNICIANS, AND THEIR RESPECTIVE SUCCESSORS, ASSIGNS, AGENTS, AND VOLUNTEERS FROM ANY AND ALL CLAIMS, CAUSES OF ACTION, DAMAGES, OR LOSSES OF ANY KIND ARISING FROM OR RELATING TO THE PROVISION OF VETERINARY CARE, INCLUDING, BUT NOT LIMITED TO, THE PERFORMANCE OF SURGICAL PROCEDURES, AS WELL AS ANY ADVERSE REACTIONS FROM VACCINATIONS OR MEDICATIONS. THIS RELEASE IS INTENDED TO RELEASE ALL NEGLIGENT ACTS OR OMISSIONS. I AGREE TO INDEMNIFY AND HOLD HARMLESS THE INDIVIDUALS OR ENTITIES DESCRIBED IN THIS PARAGRAPH FOR ANY DAMAGES CAUSED BY MY ANIMAL(S) WHILE IN THE CARE OF Memorial Veterinary Clinic OR VETERINARIAN. I have read and agree
Signature*
Date*
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