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

If YES:

Any history of seizures and/or previous aesthetic problems?

Yes

Is your pet currently on any medications?

Yes

If YES: MEDICATION :

Did your pet eat this morning?

Yes

If YES, what time:

Is your pet vomiting?

Yes

Does your pet have diarrhea?

Yes

Would you like us to update any past due vaccines during your pet's visit (besides Rabies)?

Yes

Is your pet on a heartworm preventative?

Yes

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

Yes

Is your pet currently using flea prevention products?

Yes

Is your pet microchipped?

Yes

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

Yes

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?

Yes

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

Yes

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

Yes

CPR/DNR

In the event that Waylon 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 Waylon'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

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

Yes

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.

Date