LASTNAME

FIRSTNAME

Patient Name

Procedure

Is your pet a brachycephalic breed?(Required)

Yes

Brachycephalic form provider

APC staff to provide brachycephalic form

Is your pet currently on medication?(Required)

Yes

Medication

Dosage and Frequency

Pre-Anesthetic Bloodwork Release

Your pet is scheduled for an anesthetic procedure. In order to recognize any underlying abnormalities your pet may have, and to determine any increase in anesthetic risk, we require a pre-anesthetic blood profile be completed. This complete blood cell count (CBC) and chemistry panel will check for infection/inflammation, anemia, abnormal platelet counts, blood glucose level, abnormal kidney and liver values.

Testing can significantly reduce the medical risks associated with anesthesia. A healthy-appearing pet may be hiding symptoms of disease.Testing helps us evaluate your pet’s health for selection of an appropriate anesthetic protocol to minimize the risks related to anesthesia. If pre-anesthetic results are within normal ranges, we can proceed with confidence that anesthetic risk has been minimized. However, if pre-anesthetic results are not within the normal ranges, we may recommend additional diagnostics, alter the anesthetic protocol or
reschedule the anesthetic procedure in an effort to safeguard your pet’s health and reduce the risk of potential complications. Additionally, these tests provide baseline levels for your pet and become part of his/her medical record for future reference.

For patients of all ages, pre-anesthetic bloodwork is MANDATORY.

Anesthetic and Surgery Release

Anesthetic and Surgery Release -I(Required)

I understand that the administration of anesthesia involves some risk to my pet, including rare reactions to medications and possible death. I consent to the use of medications as deemed necessary by the attending veterinarian. (Required)

Anesthetic and Surgery Release -II(Required)

I understand that all procedures and surgery also involve some risk to my pet. The most common risks include, but are not limited to, bleeding, nerve damage, and infection. (Required)

Anesthetic and Surgery Release -III(Required)

I also understand that no guarantees or assurances have been made regarding the outcome of this procedure. (Required)

Anesthetic and Surgery Release -IV(Required)

I understand that the doctors and staff at Appanasha Pet Clinic will use all reasonable precautions against injury, escape, complications, and death. (Required)

Signature(Required)

Consent/Decline Directive for Cardiopulmonary Resuscitation and Release of Legal Liability

General Information on CPR

Should, based on the medical judgment of a licensed Doctor of Veterinary Medicine, my pet named require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, emergency drugs, or other heroic interventions, I request or decline that the doctor(s) at Appanasha Pet Clinic pursue such medical care as indicated below. I have been informed by Appanasha Pet Clinic that less than 5% of animals that require CPR will survive to be discharged from the hospital. I understand that despite the best efforts of the veterinarians and staff at the Appanasha Pet Clinic, CPR may not save my pet’s life. I also understand that even if CPR is successful that my pet may never regain his/her normal mental and physical health and, thus, may leave him/her unresponsive.

RELEASE OF LEGAL LIABILITY

Regardless of whether I consent or decline to have CPR performed on my pet, in consideration for following my directive, I hereby waive, release and discharge any and all claims for damages, including, but not limited to claims for death, injury or property damage, whether or not resulting from the negligence, misconduct or other acts Appanasha Pet Clinic, its veterinarians and staff, that I may have individually or on behalf of my pet, or that may subsequently accrue, as a result of honoring this directive, and I declare that any such veterinarian, staff and the Appanasha Pet Clinic is acting in accordance with my directions. This is intended to be an advance release of legal liability, even if negligence or other misconduct occurs.

DIRECTIVE OPTIONS Select A or B(Required)

REQUEST FOR CPR. I agree that if the Appanasha Pet Clinic staff is unable to reach me within a 15 minute period after the initiation of CPR procedures, and after exercising reasonable medical judgment the veterinarian determines that there appears to be virtually no hope for medical success, further CPR procedures will cease. Having read the above general information and release, I understand the potential outcomes if CPR is performed on my pet. I agree to the terms stated and request that Cardiopulmonary Resuscitation (CPR) be performed on my pet. I understand and agree to pay the associated cost of CPR, which is $500 if performed.

DECLINE CPR – DO NOT RESUSCITATE MY PET. I have read the above information and release. I understand the terms and release as written and request that NO CPR be performed on my pet.

Owner/Agent Signature(Required)

Date(Required)

MM slash DD slash YYYY

Owner/Agent Printed Name(Required)

Best Contact Phone Number for day of the Procedure(Required)

Statement of Financial Responsibility

I, the undersigned owner or owner’s agent, of the pet identified above, certify that I am over 18 years of age and hereby authorize the doctor(s) at Appanasha Pet Clinic to perform the above anesthetic and surgical procedure(s) for my pet. I understand that some risk always exists 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(s) is/are initiated. While I accept that all procedures will be done to the best of the abilities of the staff at Appanasha Pet Clinic, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to assume financial responsibility for the services on a cash, credit card, or check basis at the time my pet is discharged from the hospital.

Owners will receive updated cost estimates whenever additional testing or precautions are necessary at the owner’s request. Appanasha Pet Clinic will also make every effort to contact owner prior to determining or performing any additional treatment that changes the original estimates, outside of emergency care which will be deemed necessary by the veterinarian.

I understand that Appanasha Pet Clinic will make every reasonable effort to contact me prior to performing additional procedures and that if I cannot be reached an additional anesthetic procedure may be required in the future to avoid keeping my pet under anesthesia longer than necessary.

Additional Services(Required)

Appanasha Pet Clinic has my permission to provide any additional services deemed medically necessary for my pet, not to exceed the following amount, if unable to reach me at the phone number provided on this form

Appanasha Pet Clinic must call me prior to any additional services being provided beyond what is included on the current estimate/treatment plan

Additional Amount(Required)

Dental Procedures

Dental Procedure(Required)

I consent to any extractions needed within the limits of the estimate provided. If extractions are expected to exceed estimate you will receive a call for approval.

This procedure is not a Dental.