Owner Name *

First

Last

first If treatment

Owner Date of Birth: *

Email *

Pet’s Name *

Date of Procedure *

Procedure(s) to be performed *

*This lists the primary procedure and may not include all pre-operative diagnostics or additional treatments included in your estimate.

Has your pet been fasted as instructed? 

Yes
No

Current medications *

Best phone number to reach you today: *

Please remain available by phone while your pet is in our care. We may contact you regarding unexpected findings, emergencies, or authorization for additional treatment.

Alternate phone number:

For dental procedures:

Additional periodontal treatment, such as extractions, periodontal therapy, or gingivectomy, may be recommended based on findings while your pet is under anesthesia. We will contact you for authorization before proceeding. If we are unable to reach you within 15 minutes of our first contact attempt, your pet will be recovered from anesthesia without the additional treatment being performed. Completing treatment at a later date may require another anesthetic procedure and additional costs. *

I understand that extractions will not be performed and that my pet will be awoken from anesthesia if I cannot be reached via telephone for consent to treatment.

Anesthesia & Procedure Information:

Anesthesia and surgical/dental procedures carry inherent risks, including rare but serious complications. ABC Veterinary Hospital Pacific Beach takes appropriate precautions to minimize these risks.

Pre-Anesthetic Testing: Bloodwork and an ECG are performed to evaluate your pet’s health and help guide the anesthetic plan.
Pre-Operative X-Rays: Chest X-rays are required for patients 8 years and older and may be required for patients with a history of a heart murmur unless otherwise discussed with the veterinarian.
IV Catheter: An IV catheter will be placed for medications, emergency access, and fluids as appropriate. Fur will be shaved for placement.
Pain Management: Appropriate pain medication will be administered. Take-home medications may be prescribed at the veterinarian’s discretion.
Flea Treatment: If fleas are found, Capstar will be administered at the owner’s expense ($25).

Additional charges may apply for unexpected findings or complications requiring additional treatment, including pregnancy, obesity, pets in heat, retained testicles, abnormal reproductive anatomy, infection, or hemorrhage.

For female patients undergoing reproductive surgery: If my pet is found to be pregnant, I authorize the veterinarian to proceed with the scheduled procedure, including termination of the pregnancy. *

I authorize
I do not authorize termination of the pregnancy. I understand that the scheduled procedure will not proceed and that I am responsible for charges for services already performed, including anesthesia and related services.
Not applicable

E-Collar

An E-collar is strongly recommended following surgical procedures to prevent licking, chewing, or disruption of the incision. *

YES, I would like an E-collar ($15–$25)
NO, I decline an E-collar. I understand that I am responsible for preventing my pet from accessing the surgical site and am financially responsible for additional treatment or surgical repair resulting from my pet disrupting the incision.
Not applicable

Spay/Neuter Tattoo

A small tattoo can be placed near the surgical area to permanently identify that your pet has been spayed or neutered. *

YES, I authorize a surgical tattoo
NO, I decline a surgical tattoo
Not applicable

CPR / DNR Directive

If my pet experiences respiratory or cardiac arrest while anesthetized or hospitalized, immediate resuscitation is required for any chance of recovery. Initial CPR, oxygen, and emergency medications may cost approximately $800 or more.

CPR – I AUTHORIZE resuscitation and emergency treatment.
DNR – I DO NOT AUTHORIZE resuscitation. I understand that no resuscitation will be attempted if my pet experiences cardiac or respiratory arrest.

Treatment & Financial Authorization

By signing below, I authorize ABC Veterinary Hospital Pacific Beach to perform the procedure(s), anesthesia, medications, diagnostics, monitoring, and medically necessary supportive care described above.

I understand that anesthesia and surgical/dental procedures carry inherent risks and that unexpected complications may occur despite appropriate precautions. If pre-anesthetic testing or diagnostics performed on the day of the procedure reveal abnormal findings, I understand that the veterinarian may postpone or cancel anesthesia or the scheduled procedure and that I remain financially responsible for services performed.

I understand that additional treatment or charges may be necessary if unexpected findings or complications occur. The hospital will make reasonable efforts to contact me when additional authorization is needed.

I have had the opportunity to ask questions regarding my pet’s procedure, risks, treatment plan, and estimated charges, and my questions have been answered to my satisfaction.

By signing below, I authorize ABC Veterinary Hospital Pacific Beach to perform the procedure(s), anesthesia, medications, diagnostics, monitoring, and medically necessary supportive care described above. I understand that anesthesia and surgical/dental procedures carry inherent risks and that unexpected complications may occur despite appropriate precautions. If pre-anesthetic testing or diagnostics performed on the day of the procedure reveal abnormal findings, I understand that the veterinarian may postpone or cancel anesthesia or the scheduled procedure and that I remain financially responsible for services performed. I understand that additional treatment or charges may be necessary if unexpected findings or complications occur. The hospital will make reasonable efforts to contact me when additional authorization is needed. I have had the opportunity to ask questions regarding my pet’s procedure, risks, treatment plan, and estimated charges, and my questions have been answered to my satisfaction. *

I understand

Owner/Authorized Agent Signature *

Clear Signature

Date *

Surgical/ Dental Anesthesia Consent Consent Form

For dental procedures:

Anesthesia & Procedure Information:

E-Collar

Spay/Neuter Tattoo

CPR / DNR Directive

Treatment & Financial Authorization

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