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Anesthesia/Sedation/Procedure/Surgical Consent

Client Information


Patient Information

Is your pet spayed/neutered?

I am the owner/authorized agent of this animal and am 18 years of age or older.

I hereby authorize the staff of Veterinary Specialists of the Rockies or its contracted agents, including, but not limited to Trek Veterinary Surgery or MoVeS Managed Services, Inc., to perform the following procedure(s), surgery or anesthesia/sedation listed above.

I also authorize the use of appropriate sedatives and/or inhalant/injectable anesthetic medications as needed for sedation or anesthesia of my pet. I also recognize that other medications such as antibiotics and analgesics may be necessary during and after the procedure for my pet and I will continue these medications at home if directed by my pet’s attending veterinarian. Additional diagnostics and supportive care measures may also be recommended or completed along with this procedure.

I understand that while performing the procedure stated above, unforeseen conditions may arise which could necessitate continued care or an altered (or additional) operation/procedure plan. I hereby authorize the procedures required as deemed appropriate by the veterinarian’s professional judgment.

I have been informed of the procedure and any possible risks that are involved with this procedure, anesthesia and/or sedation, or medications. I also understand that there is an inherent risk with anesthesia and/or sedation and complications may occur, including death. You are encouraged to discuss any concerns regarding these risks with the attending veterinarian before the procedure(s) is/are initiated. While I accept that all procedures will be performed to the best of the abilities of the staff and contracted agents at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.

I also assume full responsibility for any additional expenses incurred after the surgery, procedure or sedation/anesthesia is performed, such as follow up radiographs, bandage changes, recheck physical exams and additional surgery due to post-operative complications. Failure to comply with post-operative instructions is more likely to lead to post-operative complications and delayed healing. A complete physical exam will be performed on your pet prior to the surgical procedure if it has been longer than 30 days since the last exam. However, this may not identify all systemic or metabolic problems. Your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia, however this does not fully eliminate the risk of sedation or anesthesia. I understand that the estimate presented to me for the procedure/sedation/anesthesia is for a procedure without significant complication only.

I have read and fully understand the terms and conditions.

Did the patient eat after 10PM last evening?

Cardiopulmonary Resuscitation (CPR) Directive

I understand Veterinary Specialists of the Rockies (VSR) requires a CPR status prior to the start of any and all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or anytime in our care. I acknowledge that the attending veterinarian or staff members of VSR will make every effort to contact me regarding treatment in the case of this unforeseen event. The starting cost of CPR is approximately $400.

I am the owner / agent of this pet and ...
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