Anesthesia Authorization Form

Save time during your appointment. Complete your required anesthesia authorization form online from any device at any time before your visit.

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Anesthesia Authorization Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet before your visit.

Date of Procedure

Owner *

First

Last

Email *

Phone number where you can be reached TODAY:

Phone Type *

Phone Number *

Secondary emergency phone number:

Phone Type *

Phone Number *

Pet *

Procedure(s) to be performed:

Does your pet typically take oral medications at home to calm them for veterinary visits? *

Sedation and General Anesthesia:
I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. While all types of anesthesia involve some risk, major side effects and complications are rare. Some risks are related to and may increase in frequency depending on the pets’ overall health, age, and their unique responses to anesthetic drugs. Complications of anesthesia include but are not limited to unexpected drug reactions, corneal ulcerations, tracheal injury, esophagitis, blood clot formation, lung injury, and death.

Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me (select one and initial) *

I Authorize Camden Village Animal Hospital to perform life saving treatments on my pet. This may include the administration of medications, chest compressions, oxygen, ventilation and other emergency measures deemed medically appropriate. Camden Village Animal Hospital will make every attempt to contact me in the event of an emergency situation. I understand that I will be responsible for additional charges incurred.
I do not authorize Camden Village Animal Hospital to perform life saving treatments on my pet. I authorize the attending veterinarian to minimize pain and suffering and to make every attempt to contact me and guide me in the management of my pet’s care.

Initial *

Pre-Anesthetic Testing

Our greatest concern is the well-being of your pet. We will monitor your pet’s heart rate, respiratory rate, blood oxygen, blood pressure, and EKG during surgery. This along with pre-anesthetic blood screening reduces many of the risks of surgery.

Pre-anesthetic testing provides a more complete picture of your pet’s overall health by assessing for otherwise hidden but potentially significant health issues. It also helps minimize unexpected short—and long-term complications.

*****Pre-anesthetic bloodwork and possibly additional diagnostics that your veterinarian has discussed with you are mandatory for patients over 7 years of age.*****

Select One and Initial *

I approve the recommended pre-anesthetic testing
I decline the recommended pre-anesthetic testing

Initial *

Microchip

Would you like a microchip implanted at the time of surgery? The cost for this is $62.19 which includes registration. (select one and initial) *

Initial *

Procedure Authorization

My veterinarian has explained to me that while a satisfactory result is expected, all operations and procedures carry a risk of unsuccessful results, complications, injury, or even death from both known and unforeseen causes.

I understand that there is no certainty that my pet will achieve all of the expected operation or procedure benefits, and no guarantee has been made regarding the outcome. I have been informed of the following:
• The nature and purpose of the operation or procedure, including related care, treatment and medications.
• The potential benefits, risks or side effects of the operation or procedure and its recovery period
• The likelihood of achieving the treatment goals
• Reasonable alternatives and their relevant risks, benefits, and side effects
• The possible outcomes related to not receiving care or treatment.
• The possibility of incurring additional costs as a result of any complications

Please initial each line to confirm you have read and understood each item:

1) The Care Plan has been clearly explained to me by a doctor or staff member. Major risks of any surgery/procedure to be performed have been discussed with me by my doctor or a member of the staff. *

2) I understand that unforseen complications and/or changes in my pet’s status may occur during the hospital stay or after discharge. These complications or unexpected conditions may alter the Care Plan and will be discussed with me by my doctor or staff *

3) Updates on my pet’s status and Care Plan will be provided to me following the procedure/surgery. I will be notified promptly of any significant changes in my pet’s condition. *

I authorize that I am the decision maker for this pet and authorize the above procedure (signature): *

Clear Signature

Date *

Anesthesia Authorization Form

Anesthesia Authorization Form

Pre-Anesthetic Testing

Microchip

Procedure Authorization

Please initial each line to confirm you have read and understood each item:

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