Anesthesia Authorization Form

Owner's Name *

Pet's Name *

Daytime Phone Number *

Procedure *

Medication(s) *

Last Time Received

Your pet has been admitted for an anesthetic procedure today. Please be assured that the doctors and staff at the Animal Clinic of Spokane will use the safest anesthetics available, however, regardless of an animal’s age or apparent health status, all anesthetic procedures have an element of risk. These risks, while rare, can be serious and fatal.

I hereby consent and authorize surgery on my pets employing the use of anesthetic agents as may be considered necessary. I further understand that not all risk factors are evident upon physical examination and that routine pre-anesthetic blood testing and IV fluids are recommended.
If my animal is over 7 years of age it is required.

Pre-Anesthetic Blood Screen: A pre-anesthetic blood screen can be preformed the day of anesthesia that could help decrease the risk of anesthetic complications. This test will show liver and kidney functions as well as any evidence of anemia and can allow for extra precautions to be taken. *

YES, I want my pet to receive the pre-anesthetic blood screen for an additional charge

NO, I decline the pre-anesthetic blood screen.
If my animal is over 7 years of age it is required.

Microchip Implantation: this is a permanent identification number registered with HomeAgain, assigned to your pet *

YES, I want my pet to receive a Microchip for an additional charge

NO, I decline a Microchip

Resuscitation: In the event that your pet’s condition declines, cardiopulmonary resuscitation (CPR) can be administered. This decision to perform CPR will be based on the medical judgment of the veterinarians at Animal Clinic of Spokane. Additionally, I understand the staff will attempt to contact me as soon as possible if such need arises. *

YES, I request CPR on my pet if required, at an additional charge

NO, I decline resuscitation efforts

Owner's Consent *

I have read and fully understand this consent form. I understand that I should not sign this form if all items, including my questions, have not been explained or answered to my satisfaction, or if I do not understand the terms or wording contained in this consent form.

I understand that by checking this box I am electronically signing this document.

Today's Date *

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