Anesthesia Consent Form "*" indicates required fields Your name* First Last Your pet’s name* Procedure being performed* If mass removal(s), confirm location* As part of our commitment to offering the safest care for your pet during his/her visit for surgery, we will perform a complete physical examination prior to anesthesia. Please note any changes in your pet’s behavior in the following questions:Has your pet been fasted (had no food) since 8pm last night?* Yes No Have you noticed any recent coughing, sneezing, vomiting or diarrhea? If so, please note which symptom and the frequency:*How has your pet’s appetite been?* Increased Decreased Normal How has your pet’s thirst been?* Increased Decreased Normal How is your pet’s urination?* Increased Decreased Normal How is your pet’s defecation?* Increased Decreased Normal How is your pet’s activity level?* Increased Decreased Normal What diet is your pet currently eating?* Is your pet currently on any flea prevention?* Yes No If so, which kind? Is your pet currently on any heartworm prevention?* Yes No If so, which kind? Is your pet on any other form of medication or supplement?* Yes No If so, please tell us the name and dose In the event a medical/surgical decision must be made for the diagnostic or therapeutic care for your pet, and we are unable to contact you; how would you like us to proceed? *Please Initial*:Proceed with care at the discretion of the doctor (additional charges may apply) (You understand that this may mean not performing a procedure and may cause your pet prolonged or additional anesthesia) InitialsDo not proceed (You understand that this may mean not performing a procedure and may cause your pet prolonged or additional anesthesia) InitialsPlease understand that we will make every attempt to contact you should any unforeseen issues arise today. However, in the event of a catastrophic emergency, please elect what life-saving measures you would like performed so that we may be in accordance with your wishes: (these are at additional cost). **PLEASE INITIAL:*:Do NOT perform CPR InitialsBasic life support and CPR measures (chest compressions, artificial respiration) InitialsAdvanced life support and CPR measures (IV medications, fluids, etc) (additional charges will apply) InitialsDo you have any other questions or concerns that you would like addressed today?I certify that I am the owner, or authorized agent for the owner, of the above pet. I authorize the doctor on duty and assistants to perform the above prescribed procedures including administration of sedatives and/or anesthetics, as well as any necessary and appropriate medical, surgical, nursing, diagnostic, and/or emergency care for the above pet. I understand that San Carlos Animal Hospital is not a 24 hour hospital. Should an overnight stay be necessary, direct observation will not be available. If the above pet needs observation we recommend transfer to a 24 hour emergency hospital. I understand that during these procedures great care is taken to ensure my pet’s health, but unforeseeable conditions may occur that necessitate an extension or variance in the procedure(s) defined above. The nature of the procedure and the potential risks have been explained to me and I understand the procedure(s) to be performed. I understand that there are potentially life threatening risks with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with the veterinarian before the procedure(s) are initiated. I will not hold San Carlos Animal Hospital, the veterinarians, or any team member liable for any complications that may arise. No warranty or guarantee has been stated or implied to me as to the results or cure afforded by these treatments or procedures. My approval of this consent form indicates that any and all my questions have been answered to my satisfaction. I understand that I am assuming full financial responsibility for all services rendered at the time my pet is discharged from the hospital. Knowing that San Carlos Animal Hospital will take all precautions to make the procedure as safe as possible, I give my permission to proceed as noted above. I have read, understand, and authorize the above statements.Print Name (First, Last)* First Last Signature of Responsible Party Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY **DUE TO COVID 19, for now our new business hours areMon – Fri 7am – 5:30pm We cannot keep patients overnight**CAPTCHANameThis field is for validation purposes and should be left unchanged.