Anesthesia Consent Form Minor procedures APPOINTMENT Complete this form before your visit. Please enable JavaScript in your browser to complete this form.Client Name *FirstLastAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryEmail *Primary Phone Number *Secondary Phone NumberPet InformationPet's Name *Date of Procedure *Procedure(s) to be performed *Has your pet been fasted the night prior to the scheduled procedure? (When did your pet last eat?)Is your pet experiencing any of the following? (Please check all that apply.)Loss of appetiteDiarrheaSneezingChanges in drinking/eating habitsVomitingCoughingSeizuresDoes your pet have any other health concerns? *Is your pet currently on any medications? If so, when was the last dose given? *Has your pet ever experienced an adverse reaction to anesthesia? *YesNoDoes you pet have any allergies? (i.e. medications, food, etc.) *YesNoAs with any procedure requiring general and/or local anesthesia, there are certain risks that serious complications or even death may result. To minimize the risk of such occurrences, we mandate baseline blood work be performed in order to assure proper organ function, clotting ability, detect anemia or infection. This also gives us baseline values for future reference.Pre-anesthetic blood work (Additional fee) *I accept lab testing.I decline lab testing. I understand why pre-anesthetic blood work is recommended. I am aware of the risks and choose to proceed without blood work.As the owner of the above pet, I certify that I am over the age of 18; and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction, and cannot be held responsible for any unforeseeable results. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment, and hospitalization, and all costs associated with any complications that may arise. While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein. The doctor and staff of this facility will attempt to provide reasonable precautions against injury, escape, and/or death of each patient evaluated, admitted, and/or treated at Highlands Pet Hospital. However, the doctor and staff will not be held liable or responsible in any manner, or under any circumstances, on the account of the services rendered including treatments, surgery, safekeeping, or any and all other services administered or offered to this patient, or otherwise in connection therewith. I understand that I assume all risk. Furthermore, I understand that Highlands Pet Hospital is not staffed 24 hrs a day and staff are not continuously present to observe or monitor patients after regular business hours. Should my pet's condition warrant it, the doctor may advise (or require) the transfer of my pet to an after-hours emergency clinic or 24-hour hospital. I understand that I may request the transfer of my pet for after-hours care as well. I understand that estimates are only an estimation of fees and actual charges may be more or less than a prepared estimate indicates. I also understand that estimates do not include medications. Should unexpected life-saving emergency care be required, I would like the hospital staff to attempt the following life-saving measures (select one): *Closed chest resuscitation, including drugs, CPR, and assisted breathingDo not attempt resuscitationI acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged. I further understand that future care for this or other needs will be charged for separately.Owner's Signature (over 18 years of age) or Agent: *Clear SignatureToday's Date *PhoneSubmit