Surgery & Anesthesia Consent

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Owner's Name

Case Number (if known)

Address

Address Line 1

City

State

Owner's Phone Number

Emergency Contact Name

Emergency Contact Phone

Pet's Name

Breed

Pet's Color or Markings

Pet's Sex

Pet's Age or DOB

Signature

Clear Signature

In the event of an emergency, the doctors and staff at Quarry Ridge Animal Hospital may attempt to perform any life-saving procedures deemed necessary:

Owner's have perform

Pre-Anesthetic Chemistry/CBC (already included and required in all spays, neuters & dentals)

Pre-Anesthetic Tick screening:

Pain Management Therapeutic Laser

Was animal fasted?

Is pet current on vaccinations?

Would you like us to implant I.D. microchip?

Phone Number (where you can be reached today)

Signature

Clear Signature

I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner, over 18 years of age) of the animal described above. I have read and understand the risks associated with anesthesia and surgery. I do hereby give Dr. Donna A. Cobelli and/or her representatives full and complete authority to perform the surgical and/or anesthetic procedure(s) described below:

Advances in veterinary anesthesia and surgery have made routine procedures relatively safe. Every reasonable precaution will be taken to assure the safety of each animal under our care. Sometimes, however, there are complications associated with anesthesia and surgery that cannot be foreseen. These complications include but are not limited to: adverse anesthetic reactions, surgical problems, postoperative hemorrhage or swelling, infections, vomiting, diarrhea, anorexia, depression and even death.