Asheville Highway Animal Hospital, LLC — Anesthesia Release and Surgical Consent Online Form

Client Information
Date of Procedure*
MM slash DD slash YYYY
Client Name*
First Last
Pet's Name*
First
Phone*
Email*
Procedure(s)*
Please indicate what procedure(s) will be performed today.
Anesthesia Release
Release*
I agree to the Anesthesia Release
I understand that my pet’s procedure requires general anesthesia and /or sedation. All precautions will be taken to insure the safety of my pet. However, I have been informed of the possible risks associated with anesthesia /sedation, and that I am responsible for associated charges. I also understand that the doctor(s) reserve the right to perform lifesaving efforts should complications arise. I officially release Asheville Highway Animal Hospital of any liability pertaining to this procedure (before, during, or after surgery).
Electronic Signature*
First Last
By electronically signing you hereby agree to the consent.
Today's Date*
MM slash DD slash YYYY
Diagnostic Testing
With all anesthetic procedures, problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. To avoid these problems, we require that all patients 6 years and older be screened prior to anesthesia by means of the following laboratory test. We highly recommend this screening be done for all patients regardless of age. Please approve or decline by selecting the appropriate option below.
Screening Panel Plus*
- My pet is over 6 years of age and had blood work prior to procedure
- My pet is over 6 years of age and has NOT had blood work prior to procedure. I approve for it to be done
- My pet is under 6 years of age and had blood work prior to procedure.
- My pet is under 6 years of age and has NOT had blood work prior to procedure. I approve for it to be done.
- My pet is under 6 years of age and has NOT had blood work prior to procedure. I do NOT approve for it to be done.
Screening Panel Plus- This checks for: anemia problems, clotting blood, hidden infections, kidney or liver problems, low blood sugar, dehydration.
Electronic Signature*
First Last
By electronically signing you hereby agree or decline blood work based upon your above choice.
Today's Date*
MM slash DD slash YYYY
Additional Services
Please note any additional services that you would like us to perform while your pet is anesthetized.
Additional Services*
Hold CTRL on keyboard to select multiple at once.
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Email
This field is for validation purposes and should be left unchanged.

Client Information

Anesthesia Release

Diagnostic Testing

Additional Services