Surgical Anesthesia Consent Form | Nichols Hills Pet Clinic

General Information

Today’s Date

Date of Procedure

Client Name

First Name

Last Name

Phone Number

Email

Patient Name

IN CASE OF EMERGENCY

EMERGENCY CONTACT NAME

An emergency contact is someone who is authorized to make any major medical decision for your pet.

EMERGENCY CONTACT PHONE NUMBER

Surgical Procedure Information

Today’s procedure(s) for my pet is:

Castration/Neuter (Male)

Ovariohysterectomy/Spay (Female)

COHAT & Dental Cleaning

Mass Removal(s)

Other

Please describe IN DETAIL where the masses are located that you are wanting removed:

Please list ALL medications that your pet has been given in the last 24 hours.

Please include dosage and when the medication was given (ex: Firox 227mg, 1 tablet at 8:00pm on 1/1/26)

Additional Services Desired (additional fee applies)

PLEASE REVIEW: Surgical Procedure Information

<ul>
 	<li>Preparation:
We follow sterile procedures. We use surgical preparations, surgical packs, and surgical attire. The fur around the surgical area will
be shaved and the skin will be scrubbed with an antiseptic.</li>
 	<li>Anesthesia:
We will conduct a pre-surgical physical exam and conduct blood analysis to assess and minimize the risk of anesthesia for your
pet.</li>
 	<li>Monitoring:
We further minimize anesthetic risk by monitoring heart rate and rhythm, respiration rate and quality, blood pressure, oxygenation,
and depth of anesthesia during the procedure.</li>
 	<li>Catheterization:
For all surgical procedures, we will place an intravenous catheter to provide us with an easy route to administer medications and
fluids during the procedure. This will allow us to support kidney function and blood pressure, if necessary.</li>
 	<li>Pain Management:
We proactively manage pain associated with any procedure with appropriate pain management medications. This includes
administration of oral medications, injectable medications, and local anesthesia nerve blocks. As with any drug, side effects may be
associated with their administration.</li>
</ul>

CPR/DNR

CPR/DNR Information

I elect the following for my pet:

CPR

DNR – DO NOT RESUCITATE

Authorization

Please review and read all policies below

<ul><li>I authorize anesthesia/surgery for my pet. The nature and risks of this procedure have been explained to me and have no further inquiries.</li><li>I understand some risks always exist with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated.</li><li>My signature on this consent form indicates that any questions have been answered to my satisfaction.</li><li>If my pet is having a dental procedure, I authorize Nichols Hills Pet Clinic to perform dental extractions as deemed medically necessary.</li><li>I authorize Nichols Hills Pet Clinic to perform any diagnostic, treatment, or surgical procedure(s) deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. I understand there are rare complications associated with any anesthetic or surgical procedure.</li><li>No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures.</li><li>I fully understand these risks and understand the veterinarians and hospital staff will try to minimize such risks.</li><li>I will not hold Nichols Hills Pet Clinic, the veterinarians, or any staff member liable for any complications that may arise.</li></ul>

Signature

Clear

I HAVE READ AND FULLY UNDERSTAND ALL POLICIES STATED ON THIS ANESTHESIA CONSENT FORM. I AGREE TO FOLLOW MY PET’S PRE-SURGICAL AND POST-SURGICAL INSTRUCTIONS THAT WILL BE EXPLAINED TO ME AHEAD OF MY PET’S PROCEDURE AND FOLLOWING MY PET’S PROCEDURE.