Name *

First

Last

Email *

Date of Procedure *

Procedure(s) to be performed *

*This may not include the pre-ops or additional treatments included on your estimate; instead, this is only intended to list the name/type of the procedure

Has patient been fasted overnight?

Yes
No

List of current medications: *

In the event of updates, an emergency, and/or prior to additional procedures, you will be contacted by telephone. The phone number(s) where you can be reached today:

Phone 1 *

Phone 2

Surgical/Anesthesia Information:

As a full-service veterinary hospital, we are pleased and proud to offer you the best medical care available to your pet. Your pet's health is of utmost priority to our dedicated staff, and we take all possible precautions to ensure their safety and comfort. Although rare, unexpected complications with general anesthesia can occur.

Bloodwork & ECG: All pets undergoing anesthesia at ABC Veterinary Hospital Pacific Beach have pre-anesthetic blood testing performed to look at basic organ function and to tailor anesthetic medications used. This will also check for pre-existing medical conditions, which may increase the risk of complications during surgery. Additionally, an electrocardiogram will be performed to determine the health of your pet's heart.
Pre-Operative X-Rays: All pets undergoing anesthesia at ABC Veterinary Hospital Pacific Beach, who are 8 years or older are required to have pre-operative chest X-rays to evaluate heart size, shape, and lungs. If any patient has a heart murmur noted in their medical history, this is not optional unless discussed with a veterinarian beforehand.
IV Catheter: Your pet will have a portion of their leg(s) shaved to allow an intravenous (IV) catheter to be placed. This provides immediate access to your pet's circulatory system for rapid administration of drugs should an emergency situation arise. Your pet may also be administered intravenous fluids to help maintain normal blood pressure, protect vital organs, and maintain proper hydration.
Pain Control: All pets undergoing surgery will receive pain injections while at the clinic (which was in the initial quote). Postoperative pain management is a concern for all surgical procedures. Most procedures merit at-home oral medication for several days after surgery and will be dispensed at the veterinarian's discretion.
Flea Treatment: For the health and safety of all of our hospitalized pets, all pets housed at our facility must be free of fleas. If fleas or evidence of fleas are found on your pet, an oral rapid-acting flea treatment will be administered (Capstar) at the owner's cost ($17)

Additional elective procedures offered (please check services that you would like performed) *

Elizabethan collars ($15-25) highly recommended with most surgeries. These collars dramatically reduce the risk of your pet removing bandages and sutures that may result in additional surgery/cost to you. Please note: soft "donut" collars are not recommended.
Nail Trim (price included with Anesthetic Procedures, please authorize it by checking the box)
Anal Gland Expression ($32)
Microchip Implantation ($63)
None of the above

Surgical/Anesthetic Consent Waiver:

The nature of the procedure and the potential risks, have been explained to me and I understand the procedure(s) to be performed. I understand that some risks always exist with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any and all my questions have been answered to my satisfaction. *

I understand

I hereby request ABC Veterinary Hospital Pacific Beach to anesthetize and surgically operate on my pet. While ABC Veterinary Hospital Pacific Beach provides the highest quality of anesthesia monitoring and surgical services, I understand the risks and understand that the veterinarians and hospital team will do everything possible to minimize any risks. I understand the hospital support personnel will be used as deemed necessary by the veterinarian. Not withstanding the risk, I request the surgery and waive any and all claims of damage against ABC Veterinary Hospital Pacific Beach, its officers and employees, in the event of injury or death of my animal. *

I understand

I am aware that there are extra charges if an animal is pregnant, obese, or has an abnormal or enlarged uterus, ranging from $100-$200. There are additional charges for retained testicles, enlarged mammary glands and spays for dogs in heat, prices vary. I am aware that charges for complications arising from surgeries (including but not limited to infection, hemorrhage, or premature removal of sutures by the animal) will be at an additional charge to treat. *

I understand

For female patients only, in the event that my pet is pregnant, I understand that there is a risk of fetal death due to the medication and anesthetic administered during today's procedure. In addition I approve the abortion of fetus(es), if present I wish to take measures to preserve the fetus(es), if possible *

I understand
My pet is a male

Surgical Tattoo:

At ABC Veterinary Hospital Pacific Beach, we like to do what we can to prevent unnecessary anesthesia/risk. A surgical tattoo is a small colored line/dot that will be placed on your pet's inguinal area to reflect that he/she has been spayed/neutered. In the case your pet were to escape or become lost, one of the first things a shelter (or vet hospital) would do is search for that tattoo to determine if your pet has been spayed/neutered. We do this at the time of the surgery, and provide a local block so your pet doesn't feel a thing. Please select your wishes below if you would like your pet to receive a tattoo.

Tattoo Consent

YES, please tattoo my pet
NO, I do not want my pet tattooed

Cardiopulmonary Resuscitation (CPR) Directive

While anesthetized or hospitalized, If your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatment. If either respiratory arrest or cardiac arrest occurs, your pet will die unless immediate resuscitation attempts are started. *

I understand

I understand ABC Veterinary Hospital Pacific Beach requires a CPR status when my pet is left in their care. I acknowledge that the attending veterinarian or staff members of ABC PB will make every effort to contact me regarding treatment in the case of this unforeseen event. The initial cost of CPR, oxygen, and emergency injections starts at approximately $800.

CPR means “Cardio Pulmonary Resuscitation” and is the treatment (resuscitation) of a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet who has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of a pet with no heartbeat.
DNR means “Do Not Resuscitate.” This means that if a pet stops breathing or his/her heart stops, no effort will be made to attempt to revive the pet, and the pet will die.

I am the owner / agent of this pet and ... *

I AUTHORIZE CPR and Emergency Efforts for my pet
I DO NOT AUTHORIZE CPR and Emergency Efforts (DNR) for my pet

risk, Has and

I understand that payment is due at time of service with the exception of surgery/anesthesia/dental deposit, which is paid at the time of patient drop-off. I understand that as the owner or agent, I am financially responsible for all charges relating to this patient. I have read and agreed to this treatment authorization and have agreed to the financial obligations. *

I understand

I understand that if for any reason anesthesia and/or the procedure my pet came in for today was not completed due to abnormalities on bloodwork or preoperative diagnostics, I am financially responsible for charges incurred. *

I Agree and Understand

I understand that by signing this consent, I am consenting for my pet to be left in ABC Veterinary Hospital Pacific Beach's care and to receive the treatments/procedure(s) listed above and have had the opportunity to ask questions about charges. *

I Agree and Understand

Signature *

Clear Signature

Date *

Anesthesia & Surgery Consent Form

Surgical/Anesthesia Information:

Surgical/Anesthetic Consent Waiver:

Surgical Tattoo:

Cardiopulmonary Resuscitation (CPR) Directive

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