Anesthesia & Procedure Consent Form

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Before Your Pet’s Procedure

If your pet is scheduled for surgery, dental work, or any procedure involving anesthesia, please complete the consent form below in advance. Your pet’s comfort and safety are always our top priority.

Client Information

Name *

First

Last

Email *

Phone Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Contact Name

First

Last

* This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

Secondary Contact Phone

Today's procedure is: (example: lump removal, exam, etc.) *

Patient Information

Pet's Name *

Species *

Breed *

Color: *

Age: *

Additional Services Desired While Patient Is Sedated:

Please select any/all that you would like us to provide while your pet is sedated

I authorize anesthesia/sedation for my pet. The nature and risks of this procedure have been explained to me. I understand some risks always exist with anesthesia and/or sedation, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any questions have been answered to my satisfaction. * *

I have read, understand, and authorize.

I authorize Madison Animal Hospital to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical complications or otherwise unforseen circumstances. I understand there are rare complications associated with any anesthetic procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks and understand the veterinarians and hospital staff will try to minimize such risks. I will not hold Madison Animal Hospital, the veterinarians, or any staff member liable for any complications that may arise. * *

I have read, understand, and authorize.

Payment due upon services rendered. *

I have read, understand, and agree.

I have read and fully understand this anesthesia consent form. *

Signature *

Clear Signature

Date *

Website

Anesthesia & Procedure Consent Form

Before Your Pet’s Procedure

Client Information

Patient Information

Additional Services Desired While Patient Is Sedated:

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