Pet's Name *

Procedure(s) to be performed *

(If your pet is scheduled for a spay or neuter, the charges will be higher if the pet is in heat, pregnant, infected, or Undescended testicles) (If your pet is scheduled for declaw please indicate front, rear, or all four)

I am the OWNER OR AGENT of the above animal and have the authority to execute this consent. *

I have read and agree.

I authorize the attending veterinarian. *

I have read and agree.

I authorize the use of appropriate stress relief medication as needed before and after the procedure. *

I have read and agree.

Owner's Name *

First

Last

Email *

Phone number you can be reached at? *

Another person who can make decisions concerning my pet is

First

Last

Phone number they can be reached at?

Pre-anesthetic Blood Safety Screen

Our on-site laboratory helps us screen for hidden problems before your pets procedure begins. These tests also provide a baseline for monitoring your pet during procedures, and can indicate chemical imbalances that could affect your pet under anesthesia. No surgery is without risk, however small, thus we wil perform a pre-anesthetic blood profile to check the blood count, protein level, and kidney & liver function. If an abnormality arises the doctor will contact you and discuss the steps necessary to insure your pet's safety before, during, and after his/her procedure. Some patients may have blood work done in the previous 60 days. *

I authorize Northwest Animal Hospital to perform pre-anesthetic blood work.
My pet had blood work in 60 days
My pet has not had blood work in 60 days

Dental Cleanings/Extractions

I understand that during a dental cleaning my animal's teeth and gums will be evaluated. Dental extractions may be indicated due to exposed gums, infection, cracks, fractures, and dental radiographs. *

I authorize Northwest Animal Hospital to perform extractions which are deemed necessary.

IV Catheter Placement

Your pet will have a portion of their leg(s) shaved to all an intravenous (IV) catheter to be placed. This provides immediate access to your pet's circulatory system for rapid administration of drugs should an emergency situation arise. Your pet may also be administered intravenous fluids to help maintain normal blood pressure, protect vital organs, and maintain proper hydration. *

I have read and understand.

Consent for CPR or DNR

While hospitalized or during surgery, if your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatment. If either respiratory arrest or cardiac arrest occurs, your pet will die unless immediate resuscitation attempts are started.

You are being presented with this form because when your pet arrived at the clinic, he/she either was not breathing or had no heartbeat. Until you have read and understood this form and have asked any questions you wish answered, the staff will be starting CPR (cardiopulmonary resuscitation) at an initial estimate of $300 to $1000 in an attempt to revive your pet. If you do not wish CPR to continue, please advise a staff member IMMEDIATELY.

CPR means "Cardio Pulmonary Resuscitation" and is the treatment (resuscitation) of a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet that has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of a pet with no heartbeat.

DNR means "Do Not Resuscitate." This means that if a pet stops breathing or his/her heart stops, no effort will be made to attempt to revive the pet, and the pet will die.

Animals that have been successfully resuscitated are extremely critical and unstable. The likelihood of re-arrest is high and usually occurs within 4 hours of the initial arrest. If resuscitation is successful, there is only about a 20% chance that a pet will stay alive for the first 4 hours after resuscitation. The percentage of long term survival is even lower, and may be as low as 1%, depending upon what caused the arrest. Brain damage is common due to temporary lack of oxygen to the brain, which can result in blindness and/or impaired mental function, leaving a pet with physical and/or metal disabilities. This impairment may last for days, weeks, or years. Even in human medicine, statistics show that less than 10% of patients who are successfully resuscitated will leave the hospital without some degree of brain damage (contrary to what the television shows lead us to believe).

Management of a pet after successful initial resuscitation requires vigilant monitoring for 24 to 48 hours. This care is costly and the outcome is uncertain because a pet will still have the underlying serious problem that led to the arrest; that disease or injury must also be treated as we attempt to stabilize the pet.

Consent for CPR or DNR *

I HAVE READ AND UNDERSTOOD THE INFORMATION ABOVE OR HAD IT EXPLAINED TO MY SATISFACTION *

I request one the following: *

CPR: I elect to have CPR (Cardio Pulmonary Resuscitation) performed on my pet fi my pet were to go into Respiratory and / or Cardiac arrest. I understand that my pet may not respond initially and then suffer another arrest later. Iunderstand that my pet may die despite CPR. I understand that fi my pet survives because of CPR, eh / she may have brain damage. The estimate for initial CPR is $300 - $1000
DNR: I elect DNR (DO NOT RESUSCITATE) I understand that if my pet stops breathing and / or heart stops beating, that my pet will die unless CPR is performed. I elect to have DNR (DO NOT RESUSCITATE) orders placed in my pet's chart OR I elect that the staff IMMEDIATELY stop CPR that may have started while I was informed of the condition of my pet and my options.

The nature and risks of this procedure have been explaining to me. I understand that some risks exist with anesthesia and/or surgery and I am encouraged to discuss any concerns associated with the risks with my veterinarian before procedure(s) are started. My signature on this consent form indicates that questions have been answered to my satisfaction. I authorize Northwest Animal Hospital to perform any additional diagnostic, treatment or surgical procedure(s) deemed necessary for medical or surgical complications or any unforeseen circumstances. While Northwest Animal Hospital provides anesthesia monitoring and surgical services, I understand the risks and understand the veterinarians and hospital team will do everything possible to reduce risks. I will NOT hold Northwest Animal Hospital, the veterinarians or any team member liable for any complications that may arise. *

I HAVE READ AND FULLY UNDERSTAND THIS SURGERY AND ANESTHESAIA CONSENT FORM

Signature *

Clear Signature

Date

Surgery and Anesthesia Consent Form