Anesthesia Consent Form

Client Name

First Last

Patient Name

First Last

Phone Number

Where you can be reached during the day

Is there an alternate number you would like for us to call?

Yes
No

Alternate Phone

Would you like for us to text or call?

Text
Call

Anesthetic/Surgical procedures to be performed:

Pre-Anesthetic Blood Testing*

It is important to understand that a pre-anesthetic 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.

Intravenous Fluids*

Intravenous fluids given during surgery help maintain normal blood pressure and allow rapid administration of drugs should an emergency situation develop.

Yes, I want IV fluids used during this procedure.
I decline IV fluids for this procedure.

Microchip

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

Tattoo

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

Authorization to Perform Surgical Procedure and/or Treatments

I, the undersigned owner or owner's agent, of the pet mentioned above the hereby authorize the doctors at Louisburg Veterinary Clinic to perform the above anesthetic and surgical procedure(s) for my pet. I understand that some risk always exists with anesthesia and/or surgery, and that I am encouraged to discuss any concerns about those risks with the attending veterinarian before the procedure(s) is/are initiated.

I understand that Louisburg Veterinary Clinic 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.

Electronic Signature*

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 Clinic pursue such medical care as indicated below.

REQUEST CPR

Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $150.00 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 Clinic staff is unable to reach me within 15 minutes after the initiation of CPR procedures, and after exercising reasonable medical judgment, 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 Clinic and understand that despite the best efforts of the veterinarian and staff at Louisburg Veterinary Clinic, 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 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*

Best Contact Phone Number*

Date*

Call or Text: (919) 496-2638

115 N Church St, Louisburg, NC

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General Information on CPR

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