Anesthesia Consent Form

Thank you for trusting our veterinary team with your pet’s care. Please complete this form so we may safely proceed with anesthesia .

Owner Information

First name

Last name

Phone

Patient Information

Pet’s Name:

Has your pet eaten in the last 8 hours?

Yes

No

Does your pet have any known medical conditions?

Allergies or previous reactions to anesthesia/sedation?

Yes

No

Pre-Anesthetic Bloodwork

To reduce risks and screen for underlying conditions, pre-anesthetic testing is recommended for all pets and required for senior or medically fragile pets.

Yes, It is performed and discussed.

Yes, please perform on the day of the procedure.

I decline pre-anesthetic bloodwork and understand this increases risk.

As 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 strongly recommend that baseline bloodwork be performed to assure proper organ function, clotting ability, detect anemia or infection, and a baseline for future reference.

Risks of Anesthesia

I understand that all forms of anesthesia and sedation carry inherent risks, including (but not limited to) allergic reactions, low blood pressure, respiratory or cardiac complications, and in rare cases, death.

The veterinary team will use the safest medications and monitoring available, and will act in my pet’s best interest at all times.

CPR / Resuscitation Authorization

In the rare event that my pet’s heart or breathing stops:

Yes, perform CPR and life-saving measures. (I understand additional costs may apply.)

No, do NOT perform CPR. (I choose a Do Not Resuscitate directive.)

In the unlikely event that your pet’s heart or breathing stops during anesthesia, we want you to know we’re fully prepared to act quickly. Our veterinary team follows strict protocols and uses advanced monitoring to minimize risks.

While serious complications like cardiac arrest or apnea are rare, they are not impossible. Studies show that the risk of anesthetic-related death is around 0.17% for dogs and 0.24% for cats, meaning the chance is very low.

Consent & Signature

By signing below, I certify that:

I am the owner or authorized agent of the pet described above.

I have read and understand the information provided in this consent form.

I authorize the veterinary team to administer sedation/anesthesia and perform the described procedure(s).

I understand that no guarantees can be made regarding outcomes.

Signature

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Date

Signing date

Veterinary Anesthesia Consent Form