Grove City Veterinary Hospital

4350 Grove City Rd.
Grove City, OH 43123

(614)875-4321

www.grovecityvet.com

Sedation/Anesthesia Consent Form

Date of Procedure :
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Yes!
No, but I will
Not interested


Owner (required)
First Name (required)
Last Name (required)
Phone number where you can be reached TODAY (required)
Phone TypePhone Number (required)
Secondary emergency phone number
Phone TypePhone Number
Pet (required)

Procedure(s) to be performed

Sedation and general anesthesia:
I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. While all types of anesthesia involve some risk, major side effects and complications are rare. Some risks are related to and may increase in frequency depending on the pets’ overall health, age and their unique responses to anesthetic drugs. Complications of anesthesia include but are not limited to: unexpected drug reactions, corneal ulcerations, tracheal injury, esophagitis, blood clot formation, lung injury and death.
Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me (initial one)
I AUTHORIZE Grove City Veterinary Hospital to perform life saving treatments on my pet. This may include the administration of medications, chest compressions, oxygen, ventilation and other emergency measures deemed medically appropriate.
Grove City Veterinary Hospital will make every attempt to contact me in the event of an emergency situation. I understand that I will be responsible for additional charges incurred.

--OR--
I DO NOT AUTHORIZE Grove City Veterinary Hospital to perform life saving treatments on my pet. I authorize the attending veterinarian to minimize pain and suffering and to make every attempt to contact me and guide me in the management of my pet’s care.

Pre-Anesthetic Testing
Our greatest concern is the well being of your pet. We will monitor your pet’s heart rate, respiratory rate, blood oxygen, blood pressure and EKG during surgery. This along with pre-anesthetic blood screening reduces many of the risks of surgery.
Pre-anesthetic testing provides a more complete picture of your pet’s overall health by assessing for otherwise hidden but potentially significant health issues, and helps minimize unexpected short and long term complications.
*****Pre-anesthetic bloodwork, and possibly additional diagnostics that your veterinarian has discussed with you, is mandatory for patients over 7 years of age.*****
Select one and initial. (required)

I approve the recommended pre-anesthetic testing
I decline the recommended pre-anesthetic testing


Initial

If your pet is scheduled for dental work today
Sometimes the condition of one or more teeth makes leaving them in the mouth unhealthy. Removing diseased teeth can improve the health of your pet and their quality of life.
Many times the condition of such teeth is not known until the patient is anesthetized and radiographs are taken. I understand the veterinarian will be contacting me after assessing my pet’s dental health. I will be available at the above number. Any additional treatment may be postponed if I am unable to be contacted, which may result in another anesthetic procedure. I understand I will be verbally consenting/declining treatment once contacted by the veterinarian.
Initial please

Microchip
Please initial if you would like a microchip implanted at the time of surgery. The cost for this is $59.23 which includes registration.

Financial responsibility
I understand that an estimate of the costs for veterinary services will be provided to me and that I am encouraged to discuss all fees related to such care before services are rendered and during this pet’s ongoing medical treatment.
I understand that I am responsible for all costs associated with the above approved procedure. I understand that payments are due at the time of service. Visa, Mastercard, Care Credit, Discover and cash are all accepted forms of payment.
Procedure authorization
My veterinarian has explained to me that while a satisfactory result is expected, all operations and procedures carry a risk of unsuccessful results, complications, injury or even death, from both known and unforeseen causes.
I understand that there is no certainty that my pet will achieve all of the expected operation or procedure benefits and no guarantee has been made regarding outcome. I have been informed of the following: • The nature and purpose of the operation or procedure, including related care, treatment and medications. • The potential benefits, risks or side effects of the operation or procedure and its recovery period • The likelihood of achieving the treatment goals • Reasonable alternatives and their relevant risks, benefits and side effects • The possible outcomes related to not receiving care or treatment. • The possibility of incurring additional costs as a result of any complications
Initial each line please:
1) The Care Plan has been clearly explained to me by a doctor or staff member. Major risks of any surgery/procedure to be performed have been discussed with me by my doctor or a member of the staff. (required)

2) I understand that unforseen complications and/or changes in my pet’s status may occur during the hospital stay or after discharge. These complications or unexpected conditions may alter the Care Plan and will be discussed with me by my doctor or staff (required)

3) Updates on my pet’s status and Care Plan will be provided to me following the procedure/surgery. I will be notified promptly of any significant changes in my pet’s condition. (required)

By typing my name below, I authorize that I am the decision maker for this pet and authorize the above procedure (signature): (required)

Date :

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