Pre- Anesthetic Information and Consent Form | Mount Dora Veterinary Hospital

Welcome!

We’re excited to have you and your pet! Please fill out our Pre- Anesthetic Information and Consent Form to help us get to know you both and ensure a smooth visit to Mount Dora Veterinary Hospital.

I authorize the doctors (and ancillary staff required) of Mount Dora Veterinary Hospital to perform the following surgical, or diagnostic procedure(s) on my pet,

Pet's Name:(Required)

Procedure(s):(Required)

I understand that:  This requires IV sedation and/or inhalant anesthesia  General health blood profile will be run prior to anesthesia for my pets safety  Appropriate pain medications will be administered ($21.00-$43.00 additional fee)  IV and/or SQ fluids may be administered if needed at an additional cost  When the doctors are able to examine my pet’s teeth while under anesthesia, they may find that extraction(s) are necessary  If I am paying for spay/castration with a certificate, there are additional costs involved with the surgery that are not paid for by the certificate.  If we are removing a growth, cyst, or mass, this will be done with the CO2 Laser and will be at an additional cost.  SOME OF THESE ITEMS WILL BE AT AN ADDITIONAL COST!!!

Phone number(s) where you can be reached today:(Required)

I request a phone call if extractions or additional dental work needs to be done(Required)

Yes

If you are unable to reach me by phone today, I prefer that:

My animal be awakened from anesthesia without any additional treatment(Required)

The veterinarian proceed as he/she deems necessary(Required)

If appropriate, I prefer my pet’s procedure be done with the CO2 Laser at an additional cost. This offers us a virtually bloodless procedure that produces significantly less pain and swelling. The cost ranges from $45-$85 in addition to the surgical fee.(Required)

Microchip Permanent ID Placement:(Required)

Regularly - $69 During Surgery- $59

By signing this form, I agree that the nature and purpose of the procedure, the risks involved, and the possibility of complications have been fully explained to me and I understand them. No guarantee has been given by anyone as to the results that may be obtained.

Owner or Agent’s Signature:(Required)

Date(Required)