Anesthetic Procedure Authorization Anesthetic Procedure Authorization Owner Information Name * Name First First Last Last Email * Phone * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Pet Information Pet's Name * Species * Breed * Sex * Color * Age/DOB * Procedures to be Performed PAIN MEDICATION: Your pet’s comfort is important. We proactively control pain associated with any procedure with appropriate pain management medication(s). These drugs are given before, during, and after procedures as needed. Oral pain medications will be prescribed as needed. DENTISTRY PATIENT: Please be advised that we can only accurately assess your pet’s teeth and gums under general anesthesia. For this reason, we cannot always predict if extractions or additional treatment will be needed until the procedure is being performed. By consenting to your pet’s dental cleaning you are also consenting to the extraction of any teeth, determined unsalvageable by the attending Veterinarian. PLEASE NOTE: Coronado Veterinary Hospital reserves the right to reschedule and/or cancel any procedure at any time for any reason, regardless of whether your pet has been scheduled and/or dropped off for the procedure. PLEASE CAREFULLY READ EACH QUESTION BELOW AND CIRCLE YOUR ANSWERS. Has your pet eaten within the last 8 hours? * Yes No At what time, what, and how much did your pet eat? * Have you noticed any changes in your pet’s behavior, appetite, water consumption, or overall appearance since your pet’s last examination? * Yes No Please specify: * Would you like your pet to receive pre-anesthetic blood testing? * NOTE: ALL PATIENTS AGE 8 YEARS AND OLDER ARE REQUIRED TO HAVE PRE-ANESTHETIC TESTING DONE.Our greatest concern is the well-being of your pet. Therefore, we highly recommend that your pet receive pre anesthetic blood testing. This testing will allow us to evaluate the kidneys and liver; organs involved in anesthetic safety. We can also evaluate other parameters, including a CBC and electrolytes. We are able to perform labwork on-site in our laboratory; providing immediate results. Should an abnormality exist, you will be contacted before we proceed, to ensure the safety of your pet. In some cases the procedure may require postponement and/or cancellation due to safety Accept Decline Already done Date * Would you like your pet to have an IV catheter and fluid therapy during the procedure? * NOTE: ALL PATIENTS AGE 8 YEARS AND OLDER ARE REQUIRED TO HAVE AN IV CATHETER AND FLUIDS ADMINISTERED. An IV catheter is our first line of defense in the event of an anesthetic emergency. It allows direct access to the blood stream to administer emergency medications. IV fluids aid in the maintenance of hydration as well as managing blood pressure. Fluids also help us to “flush” the system of remaining drugs. Accept Decline Are the patient's vaccines current? * Yes No Vaccines due: * If not, would you like us to update your pet's vaccines? * Yes No Check any additional/optional services you would like your pet to receive. * Anal Gland Expression Nail Trim Microchip None of these Authorization I authorize anesthesia/surgery for my pet. The nature and risks of this procedure have been explained to me. I understand that some risks exist with anesthesia and/or surgery and have been encouraged to discuss any concerns associated with these risks with the Veterinarian before the procedure(s) are started. My signature on this consent form indicates that questions have been answered to my satisfaction. I also understand that all charges are due at check-out. Signature * signature keyboard Clear Today's Date * Phone number(s) where you can be reached AT ALL TIMES TODAY: * Captcha Submit If you are human, leave this field blank.
