Anesthesia and Surgery Consent Form

Pet Name_________________________

General anesthesia involves giving medications which make your pet unconscious in order to perform painful and/or delicate procedures.  Just as in people, there is always an inherent risk involved with general anesthesia in pets, even in apparently healthy animals.  Complications can and do occur, up to and including death.  With proper pre-anesthetic examination and screening tests, as well as diligent and thorough monitoring during anesthesia, we are able to keep complications with general anesthesia to a minimum.  Even so-called “routine” surgeries, such as spays and neuters, require general anesthesia and thus have risks of complications.

Because complications can occur, albeit very rarely, in young, apparently healthy animals, we do require the same pre-anesthetic screening for all pets.  This screening includes:

·         A thorough pre-anesthetic examination to ensure that your pet is generally in good condition and healthy enough to be put under general anesthesia

·         Pre-anesthetic blood work to ensure that your pet’s vital organs are functioning properly.

·         EKG screen to measure the electrical activity of the heart.  This screens for arrhythmias, heart enlargement, and other potentially serious heart disease.

Our general anesthetic protocol includes:

·         The use of Isoflurane gas to maintain anesthesia.  This is the same gas used in many human surgeries.

·         An IV catheter and fluids to maintain blood pressure and hydration, as well as allow access to a vein for drug administration in an emergency.

·         Use of an endotracheal tube to maintain the airway, prevent aspiration of stomach contents, and allow controlled administration of anesthetic gas.

·         Computerized vital signs monitoring, which includes pulse, respiration, blood oxygen levels, blood pressure, and EKG.

We at Lakeside Animal Clinic believe pain control is exceedingly important in ensuring a smooth and comfortable recovery from surgery and anesthesia.  We use both pre-operative and post-operative pain control protocol tailored to each individual pet’s needs.

Consent

If my pet requires further treatment during anesthesia or recovery, including emergency treatment, I authorize Lakeside Animal Clinic and its doctors to (please check one):

□    Proceed with treatment without contact

□    Attempt to contact first, and if you cannot reach me, proceed with treatment

□    Do not proceed with treatment without contacting me first

I have read this form and understand there is an inherent risk associated with general anesthesia.  Although Lakeside Animal Clinic attempts to minimize these risks, I understand that complications do occur.  By signing below, I am declaring that I understand these risks and will not hold Lakeside Animal Clinic liable.  I hereby consent to my pet being put under general anesthesia at the discretion of the doctors at Lakeside Animal Clinic.

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Signature                                                                      Date

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Printed Name

Contact Phone Number(s)    (          ) ______________  (          )________________