Anesthesia Consent Form

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Client Name

First Last

Patient Name

Phone Number

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I understand that Louisburg Veterinary Hospital is not staffed overnight and I accept any risks incurred by leaving my animal overnight unattended. I understand that I have the option to transport my animal to an overnight/24-hour facility if I so desire.

I understand a written estimate for these services will be made available upon my request and that I will provide a 50% deposit for the estimated fees.

In an effort to maintain a flea-free hospital, if fleas are found on my pet upon admittance to Louisburg Veterinary Hospital, I agree to treatment with an appropriate oral or topical flea treatment to prevent spread of those parasite to other hospitalized patients. I understand I will be charged for this treatment.

I understand that Louisburg Veterinary Hospital is not responsible for personal belongings that are left with your pet. We do provide towels and blankets in the cages where all patients are kept.

While I accept that all procedures will be performed to the best of the abilities of the hospital's staff, I understand that no guarantee has been made regarding the results that may be achieved. I agree to assume financial responsibility and provide payment at the time that services are rendered.

Preanesthetic Blood Testing

It is important to understand that a preanesthetic profile does not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future. Our greatest concern is the well being of your pet. We will perform a physical examination before administering anesthesia. However, disorders of the liver, kidneys or blood, are not detected unless blood testing is done. Abnormalities of any of these may increase anesthetic risk. For these reasons we highly recommend pre-anesthetic blood screens.

Yes, I want the pre-anesthetic blood work.

I decline the recommended pre-anesthetic blood-work and understand the surgical risks.

Microchip

I authorize the doctor to microchip my pet while under anesthesia.

I decline microchip.

If your pet has retained deciduous (baby) teeth, do we have permission to extract the teeth at the time of the surgery?

I authorize the extractions.

I decline the extractions.

Tattoo

I authorize for my pet to be tattooed to identify that it has been spayed or neutered.

I decline the tattoo.

I, the undersigned owner, or the owner’s authorized agent, of the pet identified above, hereby authorize the doctors at Louisburg Veterinary Hospital and to perform the indicated anesthetic and surgical procedure(s) for my pet.

I understand that anesthesia and surgical procedures involve inherent risks, and that no guarantee or assurance has been made regarding the outcome. I acknowledge that I have the opportunity to discuss any questions or concerns about these risks with the attending veterinarian prior to the procedure(s) being performed.

By signing below, I confirm that I have read, understand, and authorize the procedure(s) as described.

Electronic Signature(Required)

General Information on CPR

Consent/Decline Directive for Cardiopulmonary Resuscitation and Release of Legal Liability

Should, based on the medical judgement of an Animal Diagnostic Veterinarian, my pet require cardiopulmonary resuscitation (CPR) including cardiac compression, positive pressure respiration, emergency drugs, or other heroic interventions, I request or decline that the doctor(s) at Louisburg Veterinary Hospital pursue such medical care as indicated below.

REQUEST CPR

Request for CPR: Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $190.00 to pay for the services performed while staff members pursue treatment and try to reach me for further directions. Regardless of my pet's survival, I agree to pay this fee in addition to the other fees already identified by the practice and agreed upon by me. I agree that if the Louisburg Veterinary Hospital staff is unable to reach me within 15 minutes after the initiation of CPR procedures, and after exercising reasonable medical judgement, a veterinarian determines that there appears to be virtually no hope for medical success, the future CPR procedures will cease. I have been informed by Louisburg Veterinary Hospital and understand that despite the best efforts of the veterinarian and staff at Louisburg Veterinary Hospital, CPR may not save my pet's life. I also understand that even the most successful CPR that restores my pet's life may not allow my pet to regain his/her normal mental and physical health, and thus, may leave him/her as an invalid.

I request CPR.

DECLINE CPR

DO NOT RESUSCITATE MY PET. I have read the above information and release. I agree to the above terms and request that NO CPR BE PERFORMED ON MY PET.

I decline CPR.

Electronic Signature(Required)

Best Contact Phone Number(Required)

Date(Required)

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Louisburg Veterinary Hospital

115 N Church St
Louisburg, NC 27549

Call or Text: (919) 496-2638
Fax: (919) 496-2699
Email: [email protected]

Hospital Hours

Monday-Friday: 8:00 AM – 5:30 PM
Saturday: 8:00 AM – 12:00 PM
Closed Sunday