Anesthesia Authorization Form at Rutherford Veterinary Hospital Anesthesia Authorization Form Owner's Name * Owner's Name First First Last Last Pet's Name * Procedure * When did your pet last eat? * Drink? * How will you be paying for your services? * Cash Check Credit Card Pets anesthetized at our hospital are monitored with state of the art equipment. Anytime anesthesia is administered or surgery is performed there are risks, regardless of how small. To minimize these risks a full physical examination will be performed on your pet. In addition to the physical examination, Rutherford Veterinary Hospital STRONGLY RECOMMENDS pre-operative blood which checks for any systemic infections, liver or kidney disorders, diabetes and anemia. This pre-operative blood screening helps to further lower risk of anesthesia and /or the surgical procedure. Yes, I wish for the pre-operative blood screening to be performed Yes, I wish for post-operative pain control to be administrated to my pet if needed Would you like your pet micro-chipped while he/she is here? Yes No This permanent identification number can be read by animal control, emergency clinics and veterinary clinics, so that should your pet become lost or stolen its safe return is assured. I, the under signed, consent to the administration of anesthesia and authorize Rutherford Veterinary Hospital to preform the surgical and additional procedures listed above on my pet. I also authorize Rutherford Veterinary Hospital to do whatever is necessary should a surgical complication or emergency arise and I accept responsibility for any additional expenses incurred. Signature * signature keyboard Clear Phone * Email * Captcha Submit If you are human, leave this field blank.
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