Surgery/Anesthesia Consent Form

One of our veterinarians will examine your pet prior to anesthesia today. The exam will be one of our first lines of defense in detecting potential problems with your pet prior to anesthesia. The exam will cover checking your pet's eyes, nose, lymph nodes, heart, lungs, hydration, circulation and general condition. If problems are found which may significantly increase the risk of anesthesia or warrant additional care, these problems will be discussed with you prior to proceeding with the anesthesia. Some risk exists with all general anesthesia. We encourage you to discuss the anesthesia and procedures as well as the potential risk with your veterinarian.

Your pet will have a blood profile performed before anesthesia. The profile includes eight tests used to evaluate your pet's:

1. White Blood Cells for infection, inflammation or leukemia
2. Red Blood Cells for signs of anemia
3. Platelets which are critical for proper clotting function
4. Blood Protein which is important for proper healing
5. Blood Urea Nitrogen (BUN) and creatinine to assess kidney function
6. Blood Glucose (sugar)
7. Alanine Aminotransferase (ALT) to assess liver inflammation
8. Electrolytes (K, Na, Cl)

The safest anesthesia medications and techniques will be tailored to your pet's individual needs in order to maximize safety and minimize discomfort. EKG, Pulse Oximetry, Cardiopulmonary (heart & respiratory) monitoring equipment is used in all anesthetic procedures as a standard. In addition, an intravenous (IV) solution will be administered to your pet during anesthesia to ensure proper electrolyte levels and adequate blood pressure. This IV catheter also ensures that we have emergency venous access. Any patient undergoing procedures that may result in discomfort receive medication to minimize and prevent pain before and sometimes during (local blocks) their general anesthesia procedure. Additionally, post-operative pain medications will be administered.

A heat support pad/blanket will be used during the anesthesia procedure to maintain body temperature and to provide a cushion between your pet and the table to minimize discomfort.

Additional safety and care protocols we take to ensure the health and safety of your pet during the procedure:

• A Forced Warm Air blanket will be used during the anesthesia procedure to maintain body temperature and to provide a cushion between your pet and the table to minimize discomfort.
• Our surgeons wear sterile gowns, sterile gloves, cap and mask during all major surgical procedures to protect your pet's sterility.
• All major surgical procedures are performed in a sterile, enclosed operating room inspected and accredited by the American Animal Hospital Association.
• Our anesthetic, surgical and nursing protocols are routinely reviewed and accredited by the American Animal Hospital Association.
• Our surgical instrument packs and equipment are sterilized between patients.
• Post-anesthetic and recovery monitoring will be performed by a Registered Veterinary Technician with an attention to comfort and safety.
• General anesthetic procedures are usually performed throughout the day.
• Early morning admission is designed to reduce anxiety and to allow the proper amount of time for pre-anesthetic examination, medication administration and testing to be completed.

• Yes
• No

You may call us today, at any time, should you have questions or concerns regarding your pet’s stay with us. We will call you at the number provided above when your pet's procedure has been completed to schedule a pick-up time and to discuss any post-operative care.

By signing below, I acknowledge the following: Although every effort will be made to adhere to the estimate given, the actual cost may vary based on your pet's individual needs the day of the procedure. Estimates are not a guarantee of final costs. Full payment is due at the time services are provided. I have had explained to me, and I understand, the risks and benefits associated with procedures and/or therapies planned for my pet, and I give my informed consent to this procedure(s). My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

• The reasonable medical and/or surgical options for my pet.
• Sufficient details of the procedure(s) to understand what will be performed.
• My pet's post-operative recovery details.
• The most common and serious complications.
• The length and type of follow-up care and exercise restriction required.
• The estimate of fees for all services.
• Any necessary payment arrangements.

• I have read and fully understand the terms and conditions set forth above.