Please fill out this form before your visit.

Anesthesia Authorization Form

Name *

Email *

Your pet's safety and comfort is our number one concern. Before your pet's procedure, blood work is required. This will ensure that your pet does not have any internal concerns and is healthy enough to undergo anesthesia. While under anesthesia I authorize the procedures below. My signature on this consent form indicates that I understand all risks of the procedure. I have been advised that there is an extremely small risk of death, complications, or side effects every time anesthesia is used. I will not hold Fox and Friends Animal Hospital, the veterinarians, or any staff member liable for any complications that may arise. *

I have read and understand.

Procedure *

Additional procedure information

I understand that any unforeseen conditions may be revealed during the procedure that may require more extensive or different treatment. I understand that all reasonable efforts will be made to contact me to authorize treatment. However, if these efforts are unsuccessful, I authorize the performance of any procedure or treatments that are deemed immediately necessary for the health and well-being of my pet in the professional opinion of the attending Veterinarian. Dental patients may require extractions once the veterinary team starts cleaning. I understand that extractions will be of the opinion of the attending veterinarian, and I authorize treatment as decided. *

Every procedure under anesthesia runs risk. Though we take as many steps as we can to reduce those risks such as using the safest anesthesia possible for each procedure, the risk is never zero. In the case that your pet was to suffer a cardiac or pulmonary arrest, do you authorize life-saving measures? Cost of these services are not included within estimate. You will be contacted as soon as possible. Please choose which emergency measures you would like to be performed: *

CPR: I authorize appropriate life saving measures. I understand and assume all financial responsibilities for this.
DNR: I DO NOT wish for life saving measures to be performed. I am electing "Do not resuscitate" status for my

Treatment Plans are provided before procedures for all patients. If you have not received one and would like to have one, please ask.

I have been given a treatment plan and I understand that I assume financial responsibility for all services rendered and agree to pay all charges at time of pick up *

Emergency Contact Phone: *

Date

Signature *

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