Anesthesia / Surgery Consent Form

  • Call clinic or obtain from a prior invoice
  • Call clinic or obtain from a prior invoice
  • Date Format: MM slash DD slash YYYY
  • I am the owner or agent of the owner of the above described animal and have the authority to execute this consent. I hereby authorize Brookstone Animal Hospital to perform the following procedure(s) or operation(s).
  • Intravenous Catheter:
    All patients undergoing general anesthesia will have an intravenous catheter (IV catheter) placed and will receive IV fluids during all surgical and/or dental procedures. This helps to minimize the risk of general anesthesia and to provide us direct IV access in the case of an emergency.

    I understand that placement of an intravenous catheter is required and I am responsible for the cost . I do hereby allow Brookstone Animal Hospital to place an IV catheter and to provide IV fluids during the surgery and administer medications if needed.
  • I sign and understand that placement of an intravenous catheter is required.
  • Pre-Anesthetic Labwork:
    Your pet will be undergoing sedation or general anesthesia plus a surgical and/or dental procedure today. In order to recognize any underlying abnormalities your pet may have we recommend having a pre-anesthetic blood profile run on your animal. This consists of a CBC which will check blood cells and a small chemistry panel which will check blood glucose, kidney and liver enzymes and electrolyte levels.

    These blood tests will help us to assess the health status of your pet more completely and determine if there are any additional precautions we need to take before surgery. We highly recommend a blood profile on all animals and it is required for senior animals (animals older than 7 years of age). If your pet has already had bloodwork in the past 30 days, we will not need to repeat blood tests today.

    There is an additional charge for both of these blood tests. If you decline the pre-anesthetic blood test, we will perform a PCV and Total Solids test ($11.03) to make sure your pet is not dehydrated or anemic before their procedure. We hope you understand the need for these important tests.
  • I understand that if an unforeseen problem becomes apparent on the bloodwork, surgery may not be performed at this time.
  • Microchip
    In an effort to offer permanent identification and help assist in your pet's safe return in the event he/she becomes lost, Brookstone Animal Hospital offers microchip implantation at the time of surgery. While your animal is under anesthesia, the chip, which is the size of a grain of rice, can be inserted under the skin between the shoulder blades. Each chip has an individual identification that will serve as a permanent ID for your pet. Shelters, vets and rescue teams nationwide scan for microchips in all unidentified animals and are able to call a 24hr hotline when a chip number is found.
  • Therapeutic K-Laser
    The therapeutic laser can be used to help increase blood flow, oxygen and energy. This allows for quicker healing time and less inflammation/pain while your pet is recovering.
  • Tattoo with Spay or Neuter
    If your pet is getting spayed or neutered we recommend placing a small tattoo near the incision to identify your pet has been sterilized. This procedure is not painful and free of charge.
  • Pregancy with Spay
    If your pet is found to be pregnant while it is in surgery for a spay, please select from the following:
  • I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about these risks with the attending doctor before the procedure(s) is/are initiated. I understand that during the performance of the foregoing procedure(s) or operation(s), unseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) that are set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment. I also authorize the use of appropriate anesthetics and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.

    I have been advised as to the nature of the procedures or operations and the risks involved, including the possibility of death. I realize that no guarantee can be made legally or ethically to me regarding the outcome of any procedure performed. I have carefully read and do fully understand this authorization and consent.
  • I understand these risks and sign off
  • Date Format: MM slash DD slash YYYY
  • Consent for CPR
    I understand that my above pet is undergoing general anesthesia. I have been informed that during this advanced treatment, life-threatening complications such as respiratory and/or cardiac arrest may occur requiring cardiopulmonary resuscitation (CPR). If my pet stops breathing or its heart stops beating, I realize even the most successful CPR may not restore him/her to good mental and physical health. I am aware that the practice of veterinary medicine is not an exact science and thus there are no guarantees for successful treatment. In spite of the limited likelihood of success from CPR treatment, by checking one of the following choices, I hereby request:
  • I accept that if hospital staff members are unable to reach me within 20 minutes after the initiation of CPR, and after administering reasonable treatment and there appears to be virtually no hope for medical success, CPR will be withdrawn and my pet will be humanely euthanized. I am providing the hospital with phone numbers at the top of this form at which I can be reached in the event of a decline in my pets condition.
  • Date Format: MM slash DD slash YYYY