Anesthesia Authorization Form

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Anesthesia Authorization Form

For procedures requiring anesthesia, this form provides consent and allows us to tailor anesthesia and monitoring to your pet’s specific needs for a safe and smooth experience.

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Name(Required)
Animal Type(Required)

I certify that I am the owner/caretaker of the above named pet and I hereby authorize North Haven Animal Hospital/North Colony Animal Hospital to care for the animal by performing the procedure(s) listed above.
PLEASE REVIEW THE FOLLOWING AND MARK APPROPRIATELY:
1) Intravenous catheter/intravenous fluids: Recommended for all anesthetic procedures. When in place, an intravenous catheter allows us to administer fluids intra-operatively which helps control blood pressure changes that are possible with anesthesia, as well as to rapidly administer medications in the event of an emergency. Required for all patients > 10 years. The cost of this is an additional $92 (unless already included in your estimate).
Answer to item #1(Required)
2) Pre-Anesthetic Blood Profile: There is an inherent risk to any anesthetic. We recommend blood work be performed prior to all anesthetic procedures in order to asses if anesthesia can be tolerated and/or which anesthesia drug will work best. Required for all patients over the age of 10 yrs. The cost of this is an additional $54 (unless already included in your estimate).
Answer to item #2(Required)
3) Fleas: Pets entering the hospital with fleas will be treated at the owner’s expense. Fleas are easily transmitted between patients. Any pet with fleas admitted into our hospital could spread fleas to our other patients. The cost of this is $12.
I understand these terms(Required)
4) Vaccinations: Required vaccines for admittance: Dogs-DHPP- CO, tracheobronchitis and rabies; Cats-FVRCP and rabies. Cost varies depending on which vaccines are needed.
I understand these terms(Required)
I hereby consent to and authorize the performance of the procedure(s) listed above. I understand that during the performance of this procedure(s), unforeseen conditions may occur. While North Haven Animal Hospital/North Colony Animal Hospital will do everything possible to avoid these, I have been made aware of the possible complications and risks. I understand that no sedative or anesthetic is risk free. Should an emergency arise calling for procedures in addition to those planned for today I authorize emergency treatment. I agree to pay in full for all services rendered, including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. With this knowledge, I hereby authorize North Haven Animal Hospital/North Colony Animal Hospital to anesthetize the above mentioned animal. I also release the staff of North Haven Animal Hospital/North Colony Animal Hospital from any and all claims.
All fees for services are due before the patient is released.
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