Pet Information

Pet's Name *

Species *

Canine
Feline

Breed *

Color *

Age/Date of Birth *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Approximate Weight *

Is your pet microchiped? *

Yes
No

Microchip Number

Contact Information

Owner's Name *

First

Last

Email *

Authority for Anesthesia and Surgery/Oral Surgery/Procedure

Consent for Anesthesia/Surgery & CPR Directive

Purpose of Anesthesia *

If other, please specify *

Phone number where you can be reached today *

Has the patient been fed in the last 8 hours? *

No
Yes - please discuss with a staff member

Please select all medications and supplements. You may select more than one, and you may provide more detail in the text box below. *

Prescription Flea, Tick, & Heartworm Prevention from CVH
OTC Supplements or herbal treatments (please indicate below)
Prescription medications (please indicate below)
OTC Flea & Tick Prevention
Other (please indicate below)
No preventatives, medications, or supplements

Please specify OTC supplements/herbal treatments *

Please specify prescription medications *

If other, plaese specify *

Did your pet receive the pre-surgical medications exactly as prescribed by the CVH doctor? *

Yes
No

Pre-anesthetic tests: Many conditions, including disorders of the liver, kidneys, blood problems, or certain cardiac conditions ar e not detected unless blood testing, blood pressure & ECG is performed. Such testing is especially important before any surger y and HIGHLY recommended. *

I elect pre-anesthetic blood testing for the well-being of my pet.
Pre-anesthetic blood tests have already been performed.
I decline pre-anesthetic testing and request that you proceed with anesthesia. I understand the risk to my pet if this testing is not performed.

Additional items - Is there anything else we can do for your pet today? (additional fees apply) *

What medication(s) would you like refilled *

If other, please specify *

Dental Surgery Protocol - the purpose of dental work is to remove disease from the mouth. 60% of each tooth is under the gumli ne. Disease hides there and can only be seen with dental x-rays. When disease is advanced enough, the rotten teeth require rem oval to restore your pet's health. Dental x-rays can only occur while your pet is under anesthesia. To minimize anesthesia time (f or your pet's safety), the doctor will not contact you prior to removing rotten teeth. Teeth are ONLY removed when medically indi cated *

I understand that teeth will be extracted if it is medically indictated to do so

Mass Removal Protocol - any mass that the owner wishes to have removed must be pointed out in person by the owner, and a m ember of the medical team must shave an area over the mass to ensure seamless communication. *

I would like a mass to be removed and I have indicated which masses to the medical team and have observed the masses being marked correctly

Life Support Directive - All patients treated by this hospital are required to have a Cardiopulmonary Resuscitation (CPR) or Do Not Resuscitate (DNR) code. Likely, you will not need this information, but as is common practice in human medicine, we would like you to think about how you would like us to proceed in the unlikely event of an emergency *

GREEN - CPR - I wish the staff to perform closed-chest CPR (resuscitation) on my pet if my pet suffers from cardiac or respiratory arrest. I understand that my pet may not respond to CPR and may die despite CPR. I also understand that if my pet responds to CPR it is likely that he/she will arrest again. I acknowledge that the initial cost of CPR is $200-$400 and that for necessary aftercare, I will transfer my pet to a specialty critical care monitoring hospital that could cost thousands more. I understand that the cost could substantially exceed this estimate. I understand payment will be required either during my absence or immediately upon my return. I accept this financial responsibility and agree to pay for all services rendered. I understand that the staff will contact me immediately upon the initiation of CPR and if I am not available will proceed at the discretion and under the direction of the attending veterinarian until I can be reached.
RED - DNR - I DO NOT want CPR performed on my pet. I understand that if my pet suffers from cardiac or respiratory arrest, my pet will die. I have elected to have a DNR (Do Not Resuscitate) order placed on my pet’s record. I understand that even in this unlikely event, payment will be required for services rendered prior to my pet’s arrest. I accept this financial responsibility and agree to pay for all services rendered.

I am aware of the estimated costs for today's procedure. I understand that an estimate is not an exact total, and that due to the nature of healthcare and anesthesia - there are things that are unpredictable at this time which I may be respon sible for financially. I understand the bill in total will be due at the time of discharge. *

I have read the CPR/DNR information.

Consent for Treatment

I, the undersigned, am the owner or agent for the owner of the animal described above. I have the full and exclusive authority to execute this consent and am over 18 years of age. *

I have read and understand

I give permission to doctors, staff, authorized agents, or representatives of this hospital to hospitalize, anesthetize, medicate, treat, or perform surgery on my pet. *

I have read and understand

I am aware of reasonable medical and/or surgical alternatives, explanations about what the planned procedure(s) entail, the degree of recovery I should expect, the most common and most serious complications, the length, extent, and financial expectations for follow up care required, and an estimated fee schedule to expect. *

I have read and understand

I am aware of the risks and complications associated with any surgery, anesthesia, hospitalization, procedure, and medications that may be given or dispensed for my pet. *

I have read and understand

I further understand that unforeseen conditions may arise that may necessitate additional procedures at an additional cost. *

I have read and understand

If life-saving emergency care is required, I authorize this hospital's doctors, staff, authorized agents, or representatives to provide treatment which they deem necessary until I can be reached. *

I have read and understand

I authorize the use of appropriate anxiety, anesthesia, and pain relief medication as needed before and after the procedure. *

I have read and understand

I accept that all procedures follow or exceed standards of care. *

I have read and understand

I understand that IV catheterization is in my pet's best interest and I agree to placement. There will be a shaved area on a leg due to IV catheter placement. In rare occurrences, an IV catheter may be omitted (such as a feline neuter on a patient that responded heavily to pre-medication) but this is only when it is it the patient's best interest. *

I have read and understand

I understand that if my pet remains hospitalized, there will not be overnight supervision provided. *

I have read and understand

I further understand that it can be very stressful to an animal to be hospitalized and this stress may cause underlying physical conditions to become apparent. This can result in illness and even death. While the hospital strives to provide the best in veterinary services; unfortunately, no guarantee can be made regarding the outcome of the services provided. Irelease the hospital from any and all liabilities. *

I have read and understand

Signature *

Today's Date *

Online Forms

Anesthesia/Sedation Consent Form