Hospitalization/Anesthesia Consent Form

Download & Print Form – Hospitalization/Anesthesia Consent Form or fill out the form:

Like you, our greatest concern is the well-being of your pet. Before your pet undergoes anesthesia, a veterinarian will perform a physical examination to identify any existing medical conditions that could complicate the procedure and compromise the health of your pet. Because there is always the possibility that a physical exam alone will not identify all of your pet’s health problems, we strongly recommend that a pre-anesthetic blood profile (or additional tests/procedures) be performed prior to anesthesia. These tests we recommend are similar to and equally as important as those your own physician would run if you were to undergo anesthesia. A blood profile will evaluate the function of the liver and kidneys determine a blood glucose level and will include a complete blood count.

It is important to understand that a pre-anesthetic blood profile does not guarantee the absence of complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future and equally important, give a baseline of values to compare to in the future. The following procedures are considered the “gold standard” of care and may be requested at an additional cost (please initial the procedures you are requesting or declining):

Accept/Decline (Place a checkmark in those boxes that you accept. If you decline, do not check the box.)

Electrocardiogram Screen (EKG, Lead II) $32.00Pain Medication (1-4 days to decrease post-operative pain/discomfort) $29.60Microchip (Permanent Identification) $47.99 (Regular price is $57.99)Pre-Anesthetic Blood Screen (Tests liver & kidney function, blood sugar, electrolytes, red & white blood cells) $59.50 (<7yrs) $99.00 - $140.00 (7+yrs) NOTE: Pre-anesthetic blood profiles WILL BE PERFORMED on any pet greater than 7 years old, any pet that is sick, injured, or has any pre-existing health condition as determined by the doctor’s preanesthetic physical exam of the patient.

Authorization & Risk Assessment

I authorize anesthesia/surgery for my pet. The nature and risks of this procedure have been explained to me. I understand some risks exist with anesthesia and/or surgery and I am encouraged to discuss any concerns with the veterinarian before the procedure(s) are started. My signature on this consent form indicated that questions have been answered to my satisfaction. I authorize Omaha Animal Medical Group to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical or surgical complications or any unforeseen circumstances. While Omaha Animal Medical Group has the highest quality of anesthesia monitoring and surgical services, I understand the risks and understand that the veterinarian and hospital team will do everything possible to reduce any risks. I will not hold Omaha Animal Medical Group, the veterinarian, or any team member liable for any complications that may arise.

I HAVE READ AND FULLY UNDERSTAND THIS ANESTHESIA AND SURGERY CONSENT FORM

Client Name: *

Patient's Name: *

Sex: *

Species: *

Breed: *

Today's Procedure: *

Today's Contact Information:

Contact Person 1 Name: *

Contact Person 1 Number: *

Call or Text:

Email: *

Contact Person 2 Name:

Contact Person 2 Number:

Call or Text:

Please do not fill in this field.

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Hospitalization/Anesthesia Consent Form

Accept/Decline (Place a checkmark in those boxes that you accept. If you decline, do not check the box.)