Anesthesia Release and Surgical Consent Online Form

  • Client Information

  • MM slash DD slash YYYY
  • Please indicate what procedure(s) will be performed today.
  • Anesthesia Release

  • By electronically signing you hereby agree to the consent.
  • 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. (FYI: All Spays and Neuters receive a basic kidney & liver panel included in the cost of surgery. For spay/neuter patients over 6 years old, an additional CBC is required.)
    Screening Panel Plus- This checks for: anemia problems, clotting blood, hidden infections, kidney or liver problems, low blood sugar, dehydration.
  • By electronically signing you hereby agree or decline blood work based upon your above choice.
  • MM slash DD slash YYYY
  • Additional Services

    Please note any additional services that you would like us to perform while your pet is anesthetized.
  • Hold CTRL on keyboard to select multiple at once.
  • This field is for validation purposes and should be left unchanged.