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
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