Anesthetic Consent Form - Paz Veterinary

Lots of love and compassion will be given to your pet during their time with us! This form authorizes your pet’s anesthesia and delivery of your approved care for your pet. Please fill this form out completely and accurately.

* Indicates required information

Location*

Pet’s Name*

Primary Contact Name*

First Last

Primary Phone Number*

Secondary Contact Name

First Last

Secondary Phone Number

Reason for Anesthesia*

Estimate Presented and Signed?*

We will provide an estimate after completing the form.

Hidden

REQUIRES REVIEW

REQUIRES REVIEW
No

Time of most recent meal*

Hour	Minute	AM/PM

List your pet's medications and the last time they were administered.

Medication	Hour	Minute	AM/PM

Any history of drug allergies or anesthetic complications?*

Please explain the complications*

Your pet will be professionally and responsibly evaluated and monitored before, during, and after anesthesia. The pride, love, and care we put into this process is guaranteed, the results are not. Every episode of sedation, anesthesia, or surgical procedure carries an element of risk, regardless of the age or health of the patient. We will do everything within our power to reduce that risk to the lowest achievable level. Studies have shown that on average the mortality rate from anesthesia is approximately 0.05 to 0.1% in healthy dogs and cats, and is approximately 1-2% for sick dogs and cats. We are much better than average, but not perfect. A poor outcome, up to and including death, while very rare, is possible. Your veterinarian has determined that performing today’s procedure is less risky to the present and/or future overall health of your pet than not doing today’s procedure. It is natural to feel anxiety and normal to have questions about the unfamiliar. We strive to be open and transparent in our relationship with you and your pet. We will attempt to answer your questions regarding today’s procedure with honesty and without judgement. If you have unanswered concerns regarding risk or scope of today’s procedure, please let us know so your veterinarian can address those prior to the procedure. The purpose of this form is to advise you of the risks and possible complications associated with anesthesia and surgery, and that results and/or successful outcome cannot be guaranteed. This form serves as consent and authorization for treatment of your pet as deemed medically appropriate in your veterinarian’s professional judgement. This is explicit acceptance of financial responsibility for any charges incurred during your pet’s care at PAZ Veterinary, including any unexpected emergency care and associated charges. Payment in full is due at the time of your pet’s discharge from the hospital.

We are dedicated to using our scientific knowledge and skills to protect animal health and welfare and to prevent and relieve animal suffering. Inherently, all medical procedures have both benefit and risk. The staff at PAZ Veterinary will make every reasonable effort to prevent complications arising from your pet’s illness/injury or from procedures performed in our hospitals. In the very unlikely event that your pet suffers a cardio-pulmonary arrest (defined as the abrupt and unexpected cessation of spontaneous, effective ventilation and circulation) while in our hospital it is important that we know in advance your wishes on how we should proceed. The potential need for cardio-pulmonary resuscitation (CPR) is an unpleasant subject to have to ponder, but one that is very important to review and understand. All patients admitted to PAZ Veterinary must have a resuscitation directive regardless of severity of illness. The necessity for a resuscitation directive has no correlation to expected or relative patient risk. CPR of a collapsed or unconscious patient is tailored to meet the needs of the individual but may include any or all of the following: · Chest compressions · Establishing an airway via insertion of an endotracheal tube and administration of oxygen or medications through the tube · Establishing intravenous access via insertion of an intravenous catheter and administration of fluids and injectable medications through the catheter · Injectable medications, including vasopressor (e.g. epinephrine) and vagolytic (e.g. atropine) therapy Animals that have survived cardiopulmonary arrest and have been successfully resuscitated are extremely critical and unstable. Approximately 50% of patients that are successfully resuscitated from a cardiac arrest event will suffer another cardiac arrest event while hospitalized. Management of the post-arrest patient requires vigilant monitoring and the technical expertise of dedicated critical care personnel. This continued care will require transferring your pet to a 24-hour specialty hospital, will be costly, and the ultimate outcome will be uncertain. Studies have shown that survival to hospital discharge (which is the most important measure of success) is approximately 6% for dogs and cats requiring CPR. Even the most successful CPR, while potentially saving your pet’s life, may not allow for your pet to completely regain normal mental and/or physical health and may lead to ongoing medical issues. PAZ Veterinary is committed to providing superior patient care and client service that considers the quality as well as the quantity of a pet’s life. For patients experiencing advanced disease, advanced age, multiple disease processes, or a disease considered to be terminal, it’s appropriate to consider whether aggressive measures of resuscitation (CPR) will be employed if needed. We are requesting that you choose whether or not you want us to attempt resuscitation in the unlikely event that your pet experiences cardio-pulmonary arrest. There is a short and critical window of opportunity to initiate CPR beyond which the chance of success decreases significantly. By selecting now, we will be able to act on your wishes without delay. If so directed and necessary, after we have initiated CPR, we will contact you to discuss further decisions. Please review the following options and indicate your preference.

In case of life-threatening emergency, the veterinarians and staff at PAZ Veterinary can either:

DNAR (Do Not Attempt Resuscitation) This choice indicates your wish for the staff to NOT perform CPR on your pet. Every attempt will be made to prevent complications from occurring, but in the unlikely event cardio-pulmonary arrest occurs, CPR will NOT be attempted. This option is always an acceptable choice and should be based upon your beliefs and needs.

CPR (Attempt Resuscitation) This choice indicates that you authorize all efforts and procedures determined to be appropriate by the veterinarian to try to resuscitate your pet in the unlikely event cardio-pulmonary arrest occurs. CPR is more likely to be successful in a previously healthy, young patient. Specific recommendations may be made by your veterinarian based on your pet’s condition. If CPR is effective, there are often problems that need to be addressed after resuscitation. CPR does not improve or resolve any pre-existing or underlying disease. It is important to understand that there is a cost associated with CPR, regardless of outcome. This and the cost of any additional care after CPR are in addition to your current estimate. In the event we are unable to reach you within 20 minutes after initiating CPR, and after exercising reasonable medical judgment have determined that there is no hope for success, the staff will cease further CPR procedures. This option is always an acceptable choice and should be based upon your beliefs and needs.

In case of life-threatening emergency, and if I cannot be immediately contacted, I authorize my veterinarian and the staff at PAZ Veterinary to*

I have been advised of the risks and possible complications associated with anesthesia and surgery, and that results and/or successful outcome cannot be guaranteed. I hereby consent to and authorize treatment for my pet as deemed medically appropriate in my veterinarian’s professional judgement. I accept financial responsibility for any charges incurred during my pet’s care at PAZ, including any emergency care and associated charges. I understand payment is due at the time of my pet’s discharge from the hospital and will render payment in full.

Date*

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