Anesthesia ConsentAnesthesia Consent Form Client InformationName(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Please provide the best number where you can be reached during your pet's procedure, if needed.Secondary PhoneEmail Client Birthday(Required) MM slash DD slash YYYY Patient InformationPatient Name(Required)Species(Required) Dog Cat OtherPatient Birthday (or approximate)(Required) MM slash DD slash YYYY Pre-Procedure QuestionsWhat procedure is your pet having performed?Has your pet eaten today?(Required) Yes NoIf yes, what time did they last eat?Has your pet received any medications today?(Required) Yes NoIf yes, which medications did they receive?Would you like your pet to receive a courtesy nail trim today?(Required) Yes NoWould you like your pet to receive pre-anesthetic bloodwork? We highly recommend performing pre-anesthetic bloodwork as it allows our team to catch small things that may adjust how we sedate and/or monitor your pet throughout their procedure.(Required) Yes NoWould you like your pet to receive IV fluids throughout their procedure? We highly recommend providing intravenous fluids during anesthetic procedures as it helps to support proper kidney function and blood pressure.(Required) Yes NoPolicies & ConsentWe adhere to the highest standards of care including all sterile processes, individual anesthetic protocols, dedicated technicians monitoring your pet's vital signs, IV catheters which allow us instant venous access to administer medications and/or fluids, and proactive pain management.Authorization and Risk Assessment: By authorizing anesthesia, surgery or sedation for my pet, I understand that some risks and complications always exist with anesthesia and surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedures are initiated. Risks can be increased by concurrent or underlying disease processes (particularly those involving the respiratory, cardiovascular, or central nervous system), extremes of age, poor nutritional status, dehydration, anemia, and obesity. I also understand that any surgical procedure carries with it potential risk, including hemorrhage, infection, reaction to suture material, or adhesions (internal scar tissue). Declining presurgical bloodwork and/or IV catheter/fluids may place my pet at additional risk. Dental extractions bear the afore mentioned risks as well as risk of fractures and retained root tips. In accordance with state law, dental cleanings, radiographs and extractions are generally performed by licensed RVTs under doctor supervision. I understand that the veterinarians and staff members try to minimize such risks. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I will not hold Northtown Guardian Pet Hospital, the veterinarians, or any staff member liable for any complications that may arise. I understand that I assume financial responsibility for all services rendered and that payment is due in full at the time of the procedure unless alternate arrangements have been made in advance.Consent for Anesthesia(Required) As the owner of this pet, I have read the above statement and give NGPH consent to anesthetize my animal for the procedure. I do not give consent for my pet to be anesthetized for this procedure.Please select one of the following:(Required) Northtown Guardian Pet Hospital has my permission to use their professional judgment if any additional treatment or diagnostics are needed for my pet’s welfare. This includes dental extractions or sealants during COHAT procedures. I understand this may mean additional charges not on treatment plan. I wish to be contacted before any additional treatments are performed on my pet. In the event I cannot be contacted, I authorize Northtown Guardian Pet Hospital to use their own professional judgment regarding additional treatments. This includes dental extractions or sealants during COHAT procedures. I understand this may mean additional charges not on treatment plan. I wish to be contacted before any additional treatment are performed on my pet. Northtown Guardian Pet Hospital is not authorized to perform any additional treatment without contacting me first. I understand this may mean my pet will need to come back at a later date for additional care if needed.