Home » Procedure Consent Form

Procedure Consent Form

Consent for Surgery/Anesthesia/Sedation

Pet/Patient Name(Required)

Surgery Procedures(Required)

I am the legal owner of the animal identified. I give this authorization voluntarily having been advised of all of the possible risks associated with this treatment. Important: If undergoing General Anesthesia, all food and water has been withheld since 9 PM last night. For exotics: No fasting unless otherwise instructed.

I understand that pre-anesthetic blood work will be or has been performed. I understand that this presents a profile of my pet’s blood proteins, kidney and liver functions as well as the percentage of red blood cells to better insure my pet’s ability to undergo a smooth anesthesia/sedation. In no way do these results guarantee a successful outcome. Please be aware that blood work does not detect most types of cancers or heart disease.

I understand that as part of the surgery and anesthesia protocol, pain medication will be provided during and after any painful procedure as deemed necessary by the veterinarian.

There is no such thing as a simple anesthetic procedure. An infrequent, but possible side effect of anesthesia and/or surgery is death – even in an apparently healthy animal. Precautions will be taken to prevent this from happening (ie, blood work and anesthetic monitoring), but you must be aware of the risk. Particularly animals with underlying heart disease, brachycephalic breeds (short nosed animals), kidney disease and liver disease are at a greater risk.

In the case of an emergency, do you give the doctor and his/her staff the permission to provide treatment necessary to preserve the life of your pet? (CPR/emergency care may exceed $250/15 minutes)

Does your pet have a history of any illnesses or diseases that are contagious or could complicate surgery?

(For example: Diabetes Mellitus, Heart disease, Seizures, Feline Leukemia, FIV (Feline AIDS), Liver disease, Kidney disease, Cushing’s, Addison’s, etc.)

Signature(Required)

Date(Required)

Dental Procedure

Will this be a dental procedure?(Required)

Yes

Dental Procedures(Required)

I understand if no one is able to be reached, Otay Pet Vets will proceed with any medically necessary procedures, such as but not limited to, dental extractions or treatments. I understand and assume financial responsibility for any charges that may incur unless otherwise stated.

Signature(Required)

Date(Required)

Contact Information

If there is an emergent problem, the doctor will call you. It is important that we have a phone number where you can be reached if consultation is necessary while your pet is under anesthesia.

I can be reached at the following number(Required)

Alternate phone number

In case you can not be reached, is there anyone else who may authorize treatment of your pet?(Required)

Phone number(Required)

Authorization

I have read the above and by signing agree and understand all of the procedures and complications that may be involved with my pet undergoing surgery anesthesia or sedation. I authorize Otay Pet Vets to perform such diagnostic, therapeutic and surgical procedures as described above. The nature of such services has been described to me to my satisfaction and I realize that no guarantee nor warranty can ethically or professionally be made regarding the results or cure. I understand that I assume full responsibility for all services rendered.

Signature(Required)

Date(Required)

Come See Us

2015 Birch Rd
Suite 107
Chula Vista, CA 91915

Get Directions

Procedure Consent Form

Consent for Surgery/Anesthesia/Sedation

Dental Procedure

Contact Information

Authorization

Come See Us

Business Hours