Email *

Owner Name *

Phone Number *

Emergency/Alternate Phone Number *

Patient Name *

Species *

Canine
Feline
Third Choice

Breed *

Sex/Altered *

Female/Intact
Male/Intact
Female/Spayed
Male/Neutered

Description (Color) *

Last time the patient ate? *

Any recent vomiting/diarrhea? *

Yes
No

If yes, please describe.

Has the patient been eating/drinking/behaving normally?

Yes
No

Allergies

Has the patient ever had any previous complications with anesthesia or surgery? *

Yes
No

If yes, please describe.

Diagnostic Bloodwork

While your pet is under anesthesia, we maintain a constant record of vital signs including heart rate, respiratory rate, oxygen levels, blood pressure, and temperature. This helps us to detect potential anesthetic complications early and treat them before they become life threatening. It is our job to ensure that your pet can properly process and then eliminate the anesthetic he or she is given.

Any patient over 5 or in poor health MUST have bloodwork (Comprehensive Panel, Complete Blood cell count and Thyroid check) performed within 7 days of any surgical procedures. *

I agree and understand.

If your cat has or does go outside, they are exposed and at risk of contracting 2 immunodeficient viruses, Feline Leukemia and Feline Immunodeficiency Virus.. We offer testing for these viruses *

YES - I give my consent for testing for Feline Leukemia and FIV (COST $65)
NO - I decline the recommended testing and request you proceed with anesthesia.

Before we perform any procedure requiring anesthesia, we strongly recommend running tests to confirm that your pet's organs are functioning properly and to reveal any hidden health conditions that could put your pet at risk. *

YES - I consent for bloodwork to be performed on my pet prior to anesthesia.
NO - I decline the recommended bloodwork at this time and request you proceed with anesthesia.

Dental Radiographs

It can be difficult to predict if teeth need extraction when an animal is awake because tartar and movement interfere with the assessment. Severely diseased teeth can cause considerable pain and discomfort and are a source of infections for other organ systems (liver, kidney, lungs, and heart). During the dental cleaning, the teeth are evaluated, and if found to be diseased, they may require an extraction or referral to a veterinary dentist for repair. Dental x-rays are vital in the evaluation of your pet’s dental health to allow detection of problems that cannot be seen during an oral exam, as well as an aid in making treatment strategies and to evaluate treatment outcomes.

In the event that dental extractions, minor dental surgery, or any other procedures are discovered to be necessary during my pet’s dental cleaning, I authorize the following: PLEASE CHOOSE ONE STATEMENT. *

YES - I authorize the attending veterinarian to do any extractions, minor dental surgery, and/or procedures deemed necessary while my pet is under anesthesia
NO - I do NOT want to proceed and would like referral to a specialist.

Laser Therapy

As part of our commitment to quality care, we are pleased to offer laser therapy as a safe & comfortable treatment option for your pet. We feel that laser therapy provides the best possible care for your pet.

The benefits of laser therapy are:

LESS PAIN - Laser therapy has a high beneficial effect on nerve cells which block pain transmitted by these cells to the brain and which decrease nerve sensitivity.

LESS BLEEDING - Laser beams will significantly increase the formation of new capillaries in damaged tissue that speeds up the healing process, closes wounds quickly, and reduces scar tissue.

LESS INFLAMMATION - Laser therapy has an anti-edema effect as it causes vasodilatation, but also because it activates the lymphatic drainage system (drains swollen areas). As a result, there is a reduction in swelling caused by bruising or inflammation from surgery.

Laser therapy can reduce your pet's post-operative recovery time, leading to a quicker return to normal activities.

Please indicate if you would like for your pet to receive laser therapy along with the surgical procedure he or she is having. (Cost $25) *

Yes, I give consent for laser therapy to be performed on my pet.
No, I DO NOT give consent for laser therapy to be performed on my pet.

Surgery Complications and Authorization

I understand that unforeseen conditions may be revealed during the procedures that may require more extensive or different treatments. I understand that all reasonable efforts will be made to contact me to authorize any additional treatments. However, if these efforts are unsuccessful, I authorize the performance of any procedures or treatments that are deemed immediately necessary for the health and wellbeing of my pet in the professional opinion of the attending veterinarian. *

YES - I have been advised and agree
NO - I do NOT give my consent for critical intervention should complications arise.

The veterinarian has described the procedures to be performed and has explained to my satisfaction the purpose for performing them and the risks involved with them. I realize that there can be no guarantee as to the outcome of any procedures. *

YES - I have been advised of the procedure and risks involded.

I hereby authorize anesthesia/surgery for my pet. I understand that some risks always exist with anesthesia and/or surgery. My signature on this consent form indicates that any questions have been answered to my satisfaction. While Blount Veterinary Clinic provides the highest quality of anesthesia monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical procedure. In particular, I have been advised that there is an extremely small risk of death, complications, or side effects (which can present themselves well after the procedure) every time an anesthetic is used and that I have been advised of the possibility. I acknowledge these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I will not hold Blount Veterinary Clinic, the veterinarians, or any staff member liable for any complications that may arise. *

I have read the above statement, been advised and agree.

I understand that I assume financial responsibility for all services rendered. *

YES, I understand and agree.

I am the owner, or agent of the owner, of the patient described above, am of legal age and have the authority to execute this consent. I hereby authorize and direct the veterinarians at Blount Veterinary Clinic to perform the procedure(s) described above, *

YES I agree

I will be available at the phone number(s) listed below, at ALL TIMES, during the day of the procedure. If the doctor(s) cannot reach me by phone, I authorize any treatment deemed necessary for the health of my pet. *

YES, I agree.
NO, I do NOT agree.

Signature *

Clear Signature

Date *

Dental Consent Form