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Anesthesia/Surgical Consent Form Consent Form

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Online Forms

Anesthesia/Surgical Consent Form

Thank you for choosing Florence Animal Hospital. Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Pet's Name *

Client's Name *

Email *

Did your pet eat this morning? *

Is your pet on any medications or supplements?

If yes, please specify which medications and when they were last given

Procedures requiring anesthesia are always associated with a certain amount of risk. In order to minimize that risk, and to better ensure your pet's safety while under anesthesia, we require that a presurgical exam and bloodworkbe performed prior to the procedure on all patients with no discretion of age.

Procedures to be performed: (If here for a spay, we will need to know when last known heat cycle was)

A courtesy nail trim will be provided for your pet today if needed.

Biopsy -$150 (if applicable)

Additional Elective Procedures:

Microchip ($35) *

Heartworm Test ($33.26) *

Fecal ($26) *

Clean Ears / Pluck Hair ($18) *

Anal Gland Expression ($18) *

Vaccinations *

Rabies
Da2pp
Lepto
Bordetella
FVRCP
FeLV

An IV catheter will be placedfor the safety of your pet. It is placed for the administration of medications, fluids, and emergencies as needed.This will require us to shave the fur for sterility. *

I have read and understand.

For Dentals-We will doa full mouth assessment of your petwhile under anesthesia. If there is a concern with a tooth that we deemwill be detrimental to your pets health, it will be extracted today.There are additional costs associated with dental extractions as well as additional costs for medications (antibiotics, pain medications) to go home. *

I have read and understand.

Please read the following and sign below:

I am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. I understand that some risk always exists with anesthesia, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of anesthetics and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees at the time my pet is released from the hospital. *

I have read and understand.

Date *

Phone Number *

Witness *

Signature *

Name

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We proudly serve the pets of Omaha, Florence, Fort Calhoun, Crescent IA, Ponca Hills, Raven Oaks, Benson, Omaha Country Club, Lake Cunningham, and beyond. Use the button below to request an appointment with us.

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Contact Information

Phone: 402-451-7001
Email: info@florenceanimalhospital.net

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Hours

Mon – Fri: 8 AM to 5:30 PM
Sat: 8 AM to 12 PM

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Address

8305 N 30th St.
Omaha, NE 68112

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