Owner's Name *

First

Last

Patient’s Name *

Today's Date *

Phone *

*Please provide a phone number(s) where you may be reached at ALL times while your pet is in our care.

Email *

Anesthetic Procedure Consent Form

Please provide a phone numbers where you may be reached at ALL times while your pet is in our care.

Emergency Contact Phone #1 *

Emergency Contact Phone #2 *

Procedure(s) to be performed: *

Authorization and Risk Assessment:
I authorize anesthesia and surgery for my pet. The nature and risks of this procedure(s) have been explained
to me. I understand that some risks exist with anesthesia and/or surgery. My signature on this consent form
indicates that any questions have been answered to my satisfaction.

I authorize Rocky Gorge Animal Hospital to perform additional diagnostic, treatment, or procedure(s) deemed
necessary for medical or surgical complications or otherwise unforeseen circumstances. While Rocky Gorge
Animal Hospital provides the highest quality of anesthetic monitoring and surgical services, I understand that
there are rare complications associated with any anesthetic or surgical procedure. No warranty or guarantee
has been given to me as to the results or cure afforded by these treatments or procedures.

I fully understand these risks and understand that the veterinarian and hospital staff will try to minimize such
risks. I will not hold Rocky Gorge Animal Hospital, the veterinarians, or any staff member liable for any complications that may arise.

While your pet is in our care, we always want to be prepared with your wishes. In the event your pet should go into cardiac or respiratory arrest, we need to know how you would like us to proceed.

Your pet will not be admitted into the hospital unless one of the following options are selected below *

Perform CPR: including manual ventilation, chest compressions, and medications to restore cardiac rhythm. I understand I will incur all costs associated with CPR performance, regardless of the outcome.
Do NOT perform CPR (DNR): In the event that my pet stops breathing OR his/her heart stops beating, DO NOT attempt resuscitation or any further life saving measures.

Consent of Pet Parent *

Yes, I have read and fully understand this surgery and anesthesia consent form and I agree to be bound by the terms and conditions stated in this form.

Pre-Anesthetic Testing Consent

Your pet is scheduled for a procedure that requires anesthesia. We would like to take this opportunity to recommend pre-anesthetic testing and explain why it is important to the health of your pet. Like you, our greatest concern is the well being of your pet. Before placing your pet under anesthesia, one of our veterinarians will perform a complete physical examination to identify any existing medical conditions that would 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 pre-anesthetic bloodwork to be performed prior to anesthesia. It is important to understand that a pre-anesthetic does not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future.

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PROFILE #1 CHEM 10

Recommended for healthy patients under 7 years of age. - Bun (Kidney) - ALKP (Liver) - Total Protein (Hydration) - Albumin (Protein) - Creatinine (Kidney) - ALT (Liver) - Blood Glucose

PROFILE #2 CHEM 17/CBC

Required for healthy patients over 7 years of age. - BUN (Kidney) - ALKP (Liver) - Total Protein (Hydration) - Lipase (Pancreas) - Creatinine (Kidney) - ALT (Liver) - Blood Glucose - Amylase (Pancreas) - Phosphorus (Kidney) - Bilirubin (Liver) - Cholesterol - Albumin (Protein) - GGT (Liver) - Calcium - RBC count (Anemia) - WBC count (Infection)

Please Check ONE *

PROFILE #1 : Please complete the recommended PROFILE #1 testing prior to administering anesthesia to my pet. (Bun, ALKP, Total Protein, Albumin, Creatinine, ALT, Blood Glucose)
PROFILE #2 : Please complete the recommended PROFILE #2 testing prior to administering anesthesia to my pet. (BUN, ALKP, Total Protein, Lipase, Creatinine, ALT, Blood Glucose, Amylase, Phosphorus, Bilirubin, Cholesterol, Albumin, GGT, Calcium, RBC count, WBC count)
OR : I have chosen to DECLINE the recommended testing at this time, and request that you proceed with anesthesia. I understand the risks involved with putting my pet under anesthesia without pre-anesthetic testing, and agree not to hold Rocky Gorge Animal Hospital responsible, if complications occur. Bloodwork CANNOT be declined for patients over 7 years of age.
OR: My pet has recently had pre-anesthetic bloodwork and I choose to not have any additional bloodwork profiles run at this time.

If your pet has had recently bloodwork, please provide date

Month & Year

Consent of Pet Parent *

Yes, I agree to the above pre-anesthetic testing selection.

Checking this box certifies that I agree to be bound by the terms and conditions stated in this form.

Today's Date *

Surgery & Anesthesia Questionnaire

When was the last time this patient had ANYTHING to eat? (Date & Time): *

Does the owner consent to have loose, infected, or deciduous (baby) teeth extracted by the doctor, if necessary? *

YES
NO
Not Applicable

*PLEASE NOTE: The doctor will only extract teeth in the best interest of your pet. Please be aware that tooth extractions and dental radiographs are NOT included in the price of the dental cleaning, and the owner will be responsible for the extra cost. THE OWNER WILL NOT BE CALLED FOR PERMISSION TO PULL TEETH WHILE THE PATIENT IS UNDER ANESTHESIA.

If this pet is having one or more lumps removed today, does the owner want a biopsy done? *

YES
NO
Not Applicable

Is there any possibility that this pet is pregnant? *

YES
NO
Not Applicable

Is there any possibility that this pet is currently in heat? *

YES
NO
Not Applicable

Would the owner like this pet to receive a microchip today? *

YES
NO
Not Applicable

Is there any history of allergies to medication or anesthesia? *

YES
NO

Is there any history of seizures? *

YES
NO

If yes, date of last seizure

Does this pet have a KNOWN heart murmur? *

YES
NO

Is this pet on ANY medication, including over the counter medications and monthly preventative? *

YES
NO
Not Sure

If yes, please list ALL medications and when the medication was last given:

Therapeutic Laser *

YES
NO
Not Applicable (Please note masses that are suspicious of cancer and dental(s) are not applicable)

If requested; a therapeutic laser will be used (with some exceptions) on the incision(s) to help speed the healing process, reduce pain and inflammation, and reduce the formation of scar tissue. This, along with our standard pain management medications, will provide your pet with the best in pain and wound care management.

Dual Pre Surgical Form

Anesthetic Procedure Consent Form

Pre-Anesthetic Testing Consent

PROFILE #1 CHEM 10

PROFILE #2 CHEM 17/CBC

Surgery & Anesthesia Questionnaire

Rocky Gorge Animal Hospital

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