Anesthesia/Surgery Consent Form

Name

First Last

Date

Please include the full names of anyone who is legally allowed to make medication decisions on this pet including approving and paying for services. Please note that they must be over the age of 18 in order to bring a pet in.*

Authorized Medical Decisions - Person 1

First Last

Authorized Medical Decisions - Person 2

First Last

Authorized Medical Decisions - Person 3

First Last

If a person were to bring in your pet for services but are not listed on your account, we legally cannot complete any services including, but not limited to, an examination, pick up medication, or run lab work.*

Acknowledgement on requirements for Authorized Medical Decisions Person(s)

I have read and understand

Phone

What number can you be reached at today?

Patient Name

(Note – if you do have more than one pet, we need one consent form filled out per pet.)*

If your pet has been seen at another veterinarian, please list them below so we can call them for records?*

Please check whether or not we have permission to use your pet's picture on our website and/or social media. We love sharing adorable pictures of pets!*

Yes

Digital Signature*

What can I expect will happen with my pet today? Pre-anesthesitic bloodwork and physical exam will enable us to rule out some pre-existing problems which might cause your pet to not be able to handle the anesthesia. We further minimize the anesthetic risk by state of the art monitoring the whole time your pet is asleep. This includes regular measurement of blood pressure, heart rate and rhythm, respiration rate and rhythm, oxygenation, temperature, and carbon dioxide levels. We will proactively manage pain associated with any procedure (this is a law in the state of Oregon!). For many surgical procedures we will insert an IV catheter into the leg to provide fluids which will help flush out the negative effects of the sedatives and also help us maintain the blood pressure. The catheter is VERY important in the event your pet has any kind of trouble during surgery as it allows us to give medicines directly into the vein and save your pets life. It is difficult to get drugs right into the vein in an emergency without a catheter. If a surgery is being done today, the hair will be trimmed, the site will be prepared with chlorhexidine to kill bacteria, and sterilized instruments will be used. The procedure is also done in a sterile surgical room and sterile gloves, sterile gowns, hats, and masks will be worn to help prevent infection (except in the case of a dental cleaning).*

Acknowledgement of what to expect

I have read and understand

I am the owner or authorized agent of the animal above and I have the authority to make medical decisions for this pet. I authorize the above procedure and the nature and risks have been explained. I understand that some risks always exist with any surgical or anesthetic procedure and that I am encouraged to communicate any concerns or questions. My signature on this form indicates that my questions have been answered to my satisfaction. I authorize Milwaukie Animal Clinic (MAC.) to perform any additional diagnostics or treatments deemed necessary if there are any medical or surgical complications or unforeseen circumstances. While MAC. provides state of the art anesthesia and monitoring, I understand there are rare complications associated with any anesthetic or surgical procedure. I fully understand the above and agree to not hold the hospital liable for complications that may arise.*

Acknowledgement of being Owner or Authorized Agent

I have read and understand

If there are unexpected complications, do you authorize us to perform life-saving measures (CPR, emergency drugs, etc)?*

Yes

I will pick up my pet before the hospital closes for the day (5pm on most days). If I do not pick up my pet prior to close, I acknowledge that no person is in the hospital overnight to monitor them and boarding fees ($35) will be applied to my account, which must be paid at the time of pick-up.*

Acknowledgement of pick up time and boarding fee

I have read and understand

I acknowledge that payment is due at time of service. Milwaukie Animal Clinic (MAC.) accepts cash, card, and Care Credit (the persons whose name is listed on the Care Credit card must be present for payment otherwise we cannot accept that form of payment).*

Acknowledgement of payment due time/day

I have read and understand

Please answer the following questions about your pet and discuss any “yes” answers with your technician or doctor.

Is your pet on any daily medications or supplements?*

Yes

Is your pet on monthly flea/heartworm medication?*

Yes

Has your pet ever had a seizure?*

Yes

Has your pet had any vomiting, diarrhea, or coughing in the last 2 weeks?*

Yes

Are there other pets in the home?*

Yes

Does your pet get boarded, groomed, or go to day care?*

Yes

Which pet is getting surgery today?*

Canine

Feline

Rabbit

Is your dog ever outside off leash (dog park, backyard, etc.)?*

Yes

I understand that if my pet is scheduled for a spay and was in heat and bleeding any time within the last 4 weeks, there may be an in-heat fee of $79.00*

I have read and understand

I understand that my pet cannot have food or treats past midnight the night before the surgery. Water is okay to still give.*

Yes

Is your pet scheduled for a teeth cleaning today?*

Yes

Elective procedures while my pet is asleep (Please mark those you would like us to do!)*

Microchipping Email

Anesthesia/Surgery Consent Form

Office Information

Contact

Browse