Anesthesia/Sedation Consent Form Skip to Main Content Skip to Footer

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Anesthesia/Sedation Consent Form

Pet's Name:*

Procedure:

At Animal Clinic of Grand Prairie, your pet’s safety and health is our number one priority. In order to ensure a full comprehensive approach to your pet’s treatment plan, your veterinarian or surgical technician will review all forms prior to your pet’s surgical procedure with you. Please read the following form fully and ask any questions you may have.

Estimate: I have previously received an estimate for the cost of the procedure, including a low and high total of possible costs involved. I understand what the estimate includes, and would like to proceed with today’s anesthetic procedure.

Initial:*

Feeding Instructions: As instructed prior to my surgical appointment, I have NOT fed my pet since 12 AM last night, and have not fed my pet breakfast this morning in preparation for their procedure. Unless otherwise instructed by a veterinarian (diabetic patients, etc). If your pet has been fed after 12 AM, additional costs may apply, or your pet’s procedure may be rescheduled.

Initial:*

Deciduous Teeth Removal (Spay/Neuter only): If my pet has retained baby teeth (aka deciduous teeth), I authorize the veterinarian to remove them during the procedure. I acknowledge there is an additional $46 fee, and that deciduous teeth removal decreases the risk of pain and periodontal disease.

Initial:

Sevoflurane (optional):For geriatric patients, we recommend an alternative gas anesthesia that enables them to recover more quickly. Both Isoflurane and Sevoflurane are very safe for all pets. Sevoflurane incurs an additional $53 surcharge due to the cost of the medication in addition to the regular cost.

Accept

Decline

I understand that no surgical procedure has a guarantee of success and that complications may result following the performance of the above procedures. I understand that my pet will be anesthetized and that there are risks inherent with the administration of general anesthesia and that in rare cases, death may occur as a result of anesthesia. By signing this form, I understand that there are always potential risks involved with any surgery or anesthetic procedure. In the event of an emergency, I give permission to the doctors and staff of Animal Clinic of Grand Prairie to administer life-saving measures. I understand and acknowledge that additional charges may arise if complications occur. I also acknowledge that even in the event of a fatality, I will be financially responsible for the supplies and services used for my pet. Please type your full name below as signature of acknowledgment of the above statement.

Full Name:
Today's Date:

Please provide the best phone number where you can be reached today:*

Do you prefer a call or text?*

Call

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