Informed Consent for Anesthesia & Surgery 

Owner’s Name______________________Pet__________
I, being responsible for the above described animal have the authority to grant you my consent to receive, prescribe for, treat and/or operate upon my pet.

I understand the surgery or treatment contemplated is____________________________.


Of course there’s some risk:

FoxNest will use all reasonable precautions against injury, escape or demise of your pet, but animals in stressful or unusual situations sometimes panic, hurt themselves trying to escape, get stress related diarrhea, attack other patients, get away from our handlers, and experience negative reactions to medications, anesthesia, or surgery.  Such things are risks that you assume.

I consent to the administration of such anesthesia as may be deemed proper by the doctor.  I also understand the inherent risk with anesthesia.

I acknowledge that no assurance or guarantee has been made of the results of surgery or treatment.  And that possible complications exist in any surgical or medical treatment. 

Fleas, Ticks, and Filth:  If your pet has fleas, ticks, or is covered in mud, mats, burrs, and so forth; we may charge you for a bath and/or parasite control.

Blood screening for kidney disease, liver disease, diabetes, anemia, and low protein is highly recommended.  This precaution will greatly improve anesthetic safety as well as tell us much about your pet's general health: (The fee for all these tests is just $26)   
Circle:   Wanted        Declined recommendation

Also; while your pet is under anesthesia, it’s a good time to apply the newly available dental sealants ($20)   Circle:  Yes Please              No Thanks

Dental Fluoride Treatment is also available while under anesthesia and recommended for young and middle aged pets  ($8)    Circle:  Yes Please           No Thanks

Pain Management is an automatic and included part of our surgery procedures, but we will add a small charge to your bill if we think additional pain medications are needed.

Please list or circle any extra things you want done while your pet is under anesthesia.  Toe Nails, ear cleaning, anal gland expression if needed, wart, cyst, or mole removal, minor dentistry, dewclaw removal and so forth are all things we will be glad to do for you. the fee for such things is usually free or very inexpensive.

Would you like a microchip implanted in your pet?  ($30 all inclusive)

After carefully reading the above I have signed in agreement.

_____________________________________________date____________________