Anesthetic Procedure Consent Form in Orland, CA | Mid-Valley Veterinary Hospital

Client Name*

First Last

Patient Name*

Phone*

Is your pet allergic to any medications?*

Yes
No

If Yes*

Medication	Last given

Any history of seizures and/or previous aesthetic problems?*

Yes
No

Is your pet currently on any medication?*

Yes
No

If Yes*

Medication	Last given (Date and time)	Time

Did you receive a pre-op care package?*

Yes
No

If Yes*

Medication	Last given (Date and time)	Time

Please withhold food after 8pm the night before and the morning of the procedure, water is ok.

Is your pet vomiting?*

Yes
No

Does your pet have diarrhea?*

Yes
No

Would You like us to update any past due vaccines during your pet's visit?*

Current Rabies Vaccine is mandatory, the vaccine will be given if no proof of a current vaccine is provided.

Yes
No

Is your pet on a heartworm preventative?*

Yes
No

If no, would you like us to do the necessary bloodwork to get started on a preventative?*

Yes
No

Is your pet currently using flea prevention products?*

Yes
No

Is your pet microchipped?*

Yes
No

If no, would you like to have us insert one?

Yes
No

PROCEDURE TO BE PERFORMED TODAY:

Would you like us to perform screening bloodwork on your pet before anesthesia to check the overall health of your pet’s organs?*

Please note that if your pet is 2 years of age or older blood work is mandatory.

Yes
No

Would you like us to perform a urinalysis on your pet before anesthesia to check the overall health of your pet's organs?*

Yes
No

IV fluids with IV catheter for maintenance of proper blood volume and faster recovery?*

Yes
No

Would you like us to use post-operative laser therapy to accelerate healing?*

Yes
No

If lumpectomy procedure is being performed:*

Would you like us to send out the mass to our reference laboratory for additional testing? By consenting to this service, you are acknowledging that additional charges will apply. In your own words please describe the location of the mass. Add a typed response section

Yes
No

CPR/DNR

In the event that your pet should experience cardiac or respiratory arrest while boarding, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet's status?

By consenting to this service, you are also acknowledging that certain charges will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion.

I agree to CPR being performed in case of arrest and agree to any financial obligations as a result of CPR being performed regardless of outcome.*

Yes
No

I elect a “Do Not Resuscitate” status in case of arrest.*

Yes
No

PHONE NUMBER(S) WHERE YOU CAN BE REACHED TODAY*

If you cannot be reached at the phone number provided above, we will not proceed with the procedure or treatment. This can cause delays in pick-up times, and our ability to treat your pet. You will be still be charged for any services performed.

OWNER RELEASE AND CONSENT

MVVH Orland, Inc., doing business as Mid-Valley Veterinary Hospital, will use all reasonable precautions against injury, escape, or death of your pet. I understand that anesthesia and surgery always involve some risk to your pet and agree to hold Mid-Valley Veterinary Hospital harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event complications arise and I cannot be immediately contacted at the below-listed phone number, Mid-Valley Veterinary Hospital is directed to make the decision(s) it deems best for my pet. I have read the foregoing, understand what it says, and agree.

A DEPOSIT OF 50% OF THE COST OF THE TREATMENT PLAN IS DUE AT THE TIME OF PATIENT DROP OFF FOR ALL SURGERIES AND EMERGENCIES. I ACKNOWLEDGE THAT ANY REMAINING BALANCE IS DUE AT TIME OF DISCHARGE.

Signature

Date*