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Anaesthesia and Surgery Consent Form

A free fillable anaesthesia and surgical consent form for veterinary use, with estimate acknowledgement and opt-ins built in. Type in the details, sign on screen, then print it or save it as a PDF. Patient and owner details are never stored or sent anywhere.

Admission

Admission Details

Client

Client's Details

Patient

Patient's Details

(when did they last eat?)

Procedure

Procedure & Estimate

Intravenous fluid therapy during anaesthesia

(supports blood pressure and recovery)

Pre-anaesthetic blood testing

(screens organ function before anaesthesia)

Microchip while anaesthetised, if not already microchipped

(e.g. authorised additional amount, existing conditions, medications given today)

Consent

Consent

I consent to the administration of sedation and/or general anaesthesia to the animal described above, and to the procedure(s) listed, together with any additional procedures that are reasonably necessary if an unforeseen condition is found and delay would put my animal's welfare at risk, subject to my contact election above. I understand that anaesthesia and surgery carry risks, including adverse drug reactions and, in rare cases, death, even in apparently healthy animals. I confirm that the fasting instructions given to me have been followed and that the history I have provided is accurate. I acknowledge that the estimate above is an estimate and not a fixed quote, that I will be contacted in line with my election above if costs are expected to exceed it, and that all fees are payable at discharge. I confirm that I am over the age of 18 years and am the owner, or an authorised agent of the owner, of this animal.

Owner / agent signature
Staff signature
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Anaesthesia and Surgery Consent Form

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Anaesthesia and Surgery Consent Form

Admission Details

Date of admission
Time of admission

Client's Details

First name
Last name
Address
Best contact number today
Email

Patient's Details

Name
DOB (age)
Microchip
Weight (kg)
Gender
Species
Breed
Fasted from (date / time)

Procedure & Estimate

Procedure(s) to be performed
Estimated cost from ($)
Estimated cost to ($)
If an unforeseen condition is found or costs are expected to exceed the estimate
Intravenous fluid therapy during anaesthesia
Pre-anaesthetic blood testing
Microchip while anaesthetised, if not already microchipped
Notes

Consent

I consent to the administration of sedation and/or general anaesthesia to the animal described above, and to the procedure(s) listed, together with any additional procedures that are reasonably necessary if an unforeseen condition is found and delay would put my animal's welfare at risk, subject to my contact election above. I understand that anaesthesia and surgery carry risks, including adverse drug reactions and, in rare cases, death, even in apparently healthy animals. I confirm that the fasting instructions given to me have been followed and that the history I have provided is accurate. I acknowledge that the estimate above is an estimate and not a fixed quote, that I will be contacted in line with my election above if costs are expected to exceed it, and that all fees are payable at discharge. I confirm that I am over the age of 18 years and am the owner, or an authorised agent of the owner, of this animal.

Owner / agent name
Date signed

Owner / agent signature

Admitting staff member
Role

Staff signature

Built by Dr Duncan Houston for Ask A Vet · askavet.com

Nothing typed into this form is sent to or stored by askavet.com. All data stays in your browser and leaves only in the PDF or printout you create. This template is general in nature. Check the consent and record-keeping requirements of your local veterinary regulator, and adapt the consent wording to your practice with your own adviser where needed.

Dr Duncan Houston
About the author

Dr Duncan Houston · BVSc, Veterinarian

Emergency careGeneral practiceMobile vet careFounder, ASK A VET™

Dr Duncan Houston is an Australian veterinarian with experience in emergency, general-practice and mobile veterinary care. He is the founder of ASK A VET™. This guide is educational and is not a substitute for hands-on veterinary care.

When Remember is on, this page saves your clinic's details in this browser only. Owner and patient details are never saved. It is never sent to Ask A Vet. Use Forget to remove them from this computer.