Consent for Anesthesia Form, Apex, NC | Harmony Animal Hospital

Owner Name:*

First Last

Date:*

Email:*

Enter Email Confirm Email

Patient info:*

Pet's Name Species (cat or dog)

Patient Birth Date:*

Patient Info:*

Breed	Age	Weight	Color

Patient Sex:*

Female
Spayed Female
Male
Neutered Male

What is your pet's normal diet?*

Date of last blood panel*

Additional services you would like performed for your pet today (Please inquire with our staff at check-in or by phone about the costs of these services.):*

Nail trim (courtesy)
Microchip
Anal gland expression
Preliminary hip xray
Hygiene trim/potty patch
Laser: The use of a laser during surgery reduces bleeding, inflammation, pain and the risk of infection. It also speeds healing time and is beneficial in most surgical procedures.
Other (Fill in below)
None

Other additional services requested:

For Patients undergoing dental cleaning:

Many dental problems cannot be seen until your pet is under anesthesia. Please advise us on how to proceed if we find something of concern.*

1. I authorize the doctor to perform radiographs, minor extractions and oral surgery as needed.
2. Please call me first, but proceed with radiographs or extractions if I am not available.
3. Call me first. I understand that if I cannot be reached by phone within 5 minutes, additional procedures will not be performed on my pet, and must be rescheduled in the future.

If #1 or 2: I authorize up to $________ in additional services.

Phone number I can be reached at today*

Home or Office

Phone number I can be texted at today:*

Cell

Authorized person to pick up my pet on my behalf:

First Last

ANESTHESIA CONSENT*

I authorize anesthesia and the procedure(s) described above for my pet.

I authorize anesthesia and the procedure(s) described above for my pet. The nature and risks of this procedure(s) have been explained to me. I understand that some risk exists with anesthesia and I have discussed any concerns associated with these risks with the veterinarians of Harmony Animal Hospital and their staff before the procedure(s) started. My signature on this consent form indicates that all questions have been answered to my satisfaction. I authorize the veterinarians of Harmony Animal Hospital to perform any additional diagnostics, treatments, or surgical procedures deemed necessary for medical or surgical complications and any unforeseen circumstances that may occur. While Harmony Animal Hospital provides the highest quality of anesthesia monitoring and surgical services, I understand the risks and that the veterinarian and hospital team will do everything possible to reduce these risks.

I will not hold Harmony Animal Hospital, the veterinarians, or any team member liable for any complications that may arise.

I HAVE READ AND FULLY UNDERSTAND THIS SURGERY AND ANESTHESIA CONSENT FORM.
Please understand that we may NOT contact you regarding the status of your pet prior to 4:30pm unless there is a medical emergency. In the case of a medical emergency, we will contact you immediately.

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Name

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Hospital (919) 303-3456

Resort & Spa (919) 323-8877

Consent for Anesthesia Form

Welcome to Harmony Animal Hospital!

Consent for Anesthesia

For Patients undergoing dental cleaning: