Anesthetic/Surgery Consent Form in San Jose, CA | Lincoln Avenue Veterinary Clinic

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Date

PLEASE READ EVERYTHING VERY CAREFULLY

Phone # where you can be reached today:*

Pet's Name*

Procedure(s)

It is important to understand the steps that will be taken to protect your pet and to assure best possible results. We will place an intravenous catheter & administer pain control medication to your pet as deemed fit, according to your pet's unique procedure and/or specific needs.

Please check the following IF TRUE:

I have restricted food from my pet for 12 hours.

I have not given my pet medication during the previous 24 hours, unless directed to do so.

Is your pet on any long term medication, if so please list below

My pet does NOT have any symptoms which may indicate illness other then the ones known. These symptoms

include coughing, sneezing, diarrhea, inappetance, weight loss, excessive thirst or elimination, rashes.

Long term medications:*

Please check YES or NO for the following questions:

There is an additional fee of $150.00 for the pre-anesthetic blood panel to evaluate liver & kidney function among other things. This is HIGHLY recommended; would you like this to be done today?*

Yes

ALREADY DONE (Within a Month)

Would you like us to perform a pre-surgical ECG to evaluate heart rhythm for an additional $40*

Yes

Would you like us to place a microchip in your pet today? ($52)*

Yes

Would you like a complimentary nail trim while your pet is here?*

Yes

(If you have schedule a sedation nail trim then this will NOT be complimentary)

If your pet has been debarked, or had anesthetic problems before, PLEASE describe

If a problem arises, besides what is known prior to today's procedure, and needs attention, which financially goes beyond the original estimate, we will make effort to contact you by phone to go over the options. If you cannot be reached, please indicate what we should do.

Use best judgment & do whatever is necessary. I accept all additional charges.

Use best judgment but only spend up to $200, $300, $400, Other/No Limit

Do not perform any additional procedures.

Maximum Spend

Whenever an animal undergoes anesthesia & surgery, there are risks that cannot be predicted or eliminated. The amount of risk depends on many factors, including the age, general physical condition, and the condition of the heart and other organs. Another is the type of surgery being done. Some surgical procedures are more risky then others.

PLEASE NOTE: All lump removals will have a brief consultation with a Doctor.

There are times when emergencies/unexpected medical cases arise in the hospital, which may cause us to have a delay or postpone your scheduled procedure for your pet. Every effort will be made to keep our set schedules, however some events are out of out control.

*Pick-up Policy: All pets must be picked up before 6PM. If you arrive before 6:15PM you will be charged a late fee of $15, if you arrive after 6:15PM, your pet will be boarded overnight and a boarding fee will be applied.*

initial

I understand the above and give my consent for my animal.

Signature*