Anesthesia Release Form | Frontier Veterinary Hospital

I hereby entrust Frontier Veterinary Hospital (FVH) to care for my pet during his/her surgery stay. I am the owner, or a representative of the owner, of the animal presented and have the authority to execute this consent. I have been advised as to the nature of the procedure to be performed and the risks involved. I understand the doctors and staff will use all reasonable precaution against the injury and/or death of my pet, and I hereby consent and authorize this hospital to perform the requested anesthesia and surgical procedures. In the event of unforeseen complications, I give permission to the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. I understand that I must furnish phone number(s) where FVH can reach me or a contact person whom I have authorized to make medical decisions.(Required)

I have read and understand.

ADDITIONAL TREATMENT DIRECTIVE

Procedures requiring anesthesia are time-sensitive and provide a narrow window of time in which to reach you. For your pet's safety, please list where you or your agent can be reached without delay.(Required)

I have read and understand.

Patient Name(Required)

First

Last

Name of contact person:(Required)

First

Last

This person is:(Required)

Owner

Authorized Agent

Phone Number(Required)

In the event you or your authorized contact person are not reachable, would you prefer us to proceed with any additional recommended treatment? Please select your preference:(Required)

Yes, please proceed with additional treatment. I understand that there will be additional charges for further treatments.

No, please do not proceed with any treatment beyond the initial treatment plan, unless my pet’s safety requires it.

Email(Required)

Telephone is our primary means of contacting you regarding your pet’s procedure, however we sometimes email updated estimates, forms, home care instructions, etc.

Would you like to receive status updates via text message today?(Required)

Yes

Please list phone number to text:(Required)

BLOOD TESTING

Blood testing is required within the last 2 months for pets 7 years or older, and within the last 6 months for pets under 7 years of age. I understand that blood work is an important aid in determining my pet's health, but does not guarantee a more successful surgery. *If bloodwork is not current, it will be required prior to surgery at an additional fee*(Required)

I have read and understand.

FEMALE DOGS BEING SPAYED ONLY – HEAT CYCLE – What are the approximate dates of your dog's last heat cycle (beginning-end)?

Beginning of Heat

End

LAPAROSCOPIC SPAY PROCEDURES ONLY

At Frontier Veterinary Hospital we prefer to perform ovariectomy (OVE) surgery using laparoscopy as an adjunct to traditional surgical methods because it is less invasive. However, in come cases your veterinarian may change method during the course of surgery and perform your pet's OVE in the traditional manner, without laparoscopy. This is done at the surgeon's discretion, in order to proceed with the surgical technique which is safest for the patient. If this becomes necessary, your veterinarian may need to call you post-operatively due to the time sensitive nature of anesthesia and surgery.(Required)

I have read and understand.

PICKUP AFTER SURGERY

Standard pickup time is between 6-8pm due to the nature of hospital safety procedures and anesthesia recovery. Occasionally pets may be able to go home earlier, so please provide the earliest time you are able to pick up your pet and attend a 20 minute hospital discharge appointment:(Required)

I have read and understand.

Earliest available pickup time (standard pickup is 6-8pm):(Required)

Do you have Pet Insurance?(Required)

Yes

If yes, do you plan on submitting the final invoice for insurance reimbursement?

Yes

I understand that the safety of my pet is the overriding priority. I understand that any price quote I have been given is an estimate and if complications are involved, or the procedure is of greater dimensions than anticipated, the price may be higher. I understand that by signing below, I agree to pay for all charges incurred as such and will pay the balance in full upon discharge of my pet.(Required)

I have read and understand.

Signature(Required)

Date(Required)

PRE-ANESTHESIA QUESTIONNAIRE

I have been informed of the fasting requirements for anesthesia and will not/have not fed by pet since 11pm the night before surgery:

Yes

No – if selected, please contact us immediately at 503-648-1643

Other

If Other, please explain

Is your pet on any medications?

Yes

If yes, please list name of medication(s) and when the last dose was given:

Have you recently applied a topical flea medication to your pet?

Yes

If yes, what date:

Has your pet been ill recently? If so, please describe the symptoms and indicate date/time of last symptoms:(Required)

Does your pet have an ID Microchip?(Required)

Yes

Do you have any other questions or concerns for the doctor?

Are there any additional services you would like us to perform while your pet is in the hospital (charges may apply)?

Signature(Required)

CAPTCHA

Anesthesia Release – General Surgery

ADDITIONAL TREATMENT DIRECTIVE

BLOOD TESTING

FEMALE DOGS BEING SPAYED ONLY – HEAT CYCLE – What are the approximate dates of your dog's last heat cycle (beginning-end)?

LAPAROSCOPIC SPAY PROCEDURES ONLY

PICKUP AFTER SURGERY

PRE-ANESTHESIA QUESTIONNAIRE

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

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