Anesthesia Consent Form - Flowertown Animal Hospital

We understand that leaving your beloved pet in our care—especially for a procedure requiring anesthesia—can be a stressful experience. Please know that their safety, comfort, and well-being are our top priorities. Our team is dedicated to providing the highest level of care, just as we would for our own pets.

To ensure we have all the necessary information, please take a moment to complete this form. If you have any questions or concerns, don’t hesitate to ask—we’re here for you every step of the way.

Thank you for entrusting us with your pet’s care. We look forward to seeing them through a smooth and safe procedure!

"*" indicates required fields

Name*

First Last

Email*

Patient Name*

Phone*

Species*

Dog

Cat

Exotic

If exotic:

I hereby authorize the performance of the following procedure(s):*

At what number can you be contacted at day of the procedure?*

Authorization and Risk Assessment. Please initial after each statement.

I hereby certify that I am the owner of the above-named pet or am responsible for it and have authority to execute this consent.*

I understand that unforeseen conditions may be revealed during the procedure that may require more extensive or different treatments. I understand that all reasonable efforts will be made to contact me to authorize any additional treatments. However, if these efforts are unsuccessful, I authorize the veterinarian in charge of my pets’ care to perform any procedures or treatments that are deemed immediately necessary for the health and wellbeing of my pet up to*

I understand that I will assume financial responsibility for all services rendered at the time of discharge.*

The procedure(s) to be performed has been described to me and was explained to my satisfaction the purpose for performing and the risks involved with them. I realize that there can be no guarantee as to the outcome of any procedure(s).*

I hereby authorize anesthesia/surgery for my pet. I understand that some risks always exist with undergoing anesthesia and/or surgery. My signature on this consent form indicates that any questions have been answered to my satisfaction. While Flowertown Animal Hospital provides the highest quality of anesthesia monitoring and surgical services, I understand that there are rare complications, or side effects any time an anesthetic is performed and that I have been advised of those possibilities. I acknowledge these risks and understand that the veterinarian(s) and hospital technical staff will try to minimize such risks in every way possible. I will not hold Flowertown Animal Hospital, the veterinarians, or any staff member liable for any complications that may arise.*

Please select the following:*

CPR- I authorize appropriate life saving measures. I understand and assume all financial responsibility for these additional fees that are not included in your treatment plan.

DNR- I do not wish for life saving measures to be performed. I am electing “DO NOT RESUSCITATE” status for my pet.

Would you like to have a microchip implanted while your pet is under general anesthesia or sedation?*

Decline

Would you like to have your pet tattooed to indicate it has been spayed/neutered while under general anesthesia?*

Decline

Date*

Signature*