Anesthesia / Surgical Consent Form Please fill out the form below. Anesthesia / Surgical Consent Form Name * Name First Name First Name Last Name Last Name Email * Phone * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Patient Name * Breed * Species * Canine Feline Sex Male Male/Neutered Female Female/Spayed Color * Procedure to be performed * When did the patient last eat? (Pets must be fasted overnight prior to the procedure) * Was Cerenia (anti-nausea tablet) given last night? * Yes No Was the patient given any medications this morning? * Yes No Please list names and doses, if known * What is the best phone number to reach you on the day of the procedure? (Please include any secondary phone numbers in case you cannot be reached right away at the primary number.) * By checking the boxes below you grant permission for Olmito Veterinary Hospital to perform the recommended service(s) and fully acknowledge and accept risks associated with anesthesia and surgical procedure(s). * I, the undersigned owner or agent of the pet identified above, authorize the staff of Olmito Veterinary Hospital to perform the above procedures. I understand that some risks always exist with sedation and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedures are initiated. While accept that all procedures will be performed to the best of the abilities of the staff at Olmito Veterinary Hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I assume full responsibility for any additional expenses incurred after the sedated procedure is performed, such as follow up radiographs, re-check physical exams, and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have read and fully understand the terms and conditions set forth. Additional questions regarding the recommended procedure: * Signature * signature keyboard Clear Date * Submit If you are human, leave this field blank.
