Anesthesia Consent Form Your name* First Last Your pet’s name* Procedure being performed* 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 Please understand that we will make every attempt to contact you should any unforeseen issues arise today. If you cannot be reached immediately when a decision must be made for the care of your pet, how would you like us to proceed? *PLEASE MAKE A SELECTION BELOW:Please select one* Proceed with care at the discretion of the doctor (additional charges may apply) Do not proceed (You understand that this may mean not performing a procedure and may cause your pet prolonged or additional anesthesia) Do you have any other questions or concerns that you would like addressed today?I understand that there are potentially life threatening risks involved with any surgical or anesthetic procedure. 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.Sign HereDate* MM slash DD slash YYYY **DUE TO COVID 19, for now our new business hours areMon – Sat. 8a – 5p. We cannot keep patients overnight**CAPTCHAEmailThis field is for validation purposes and should be left unchanged.