Anesthesia Consent - Eastern Shore Animal Hospital & Urgent Care

Owner Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Pet Name*

Species*

Breed*

Sex*

Male
Female

Color*

Weight*

Anesthetic/Surgical procedure(s) to be performed:

- I, as the owner or authorized agent of owner, grant my consent for Eastern Shore Animal Hospital to receive, prescribe for, treat and/or operate upon the above named pet. It is understood that there is inherent risk associated with medical and surgical treatments. Specific results can never be guaranteed in dealing with the complexities of living animals.
- I understand that unforeseen complications can result even though professional, approved, methods will be used by the team at Eastern Shore Animal Hospital.
- While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.
- I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions.

Please read carefully and choose one of the following pertaining to emergency life saving procedures:*

Should an emergency arise, I give permission to ESAH doctors and staff perform any necessary life saving measures on my pet.
I do NOT give my consent to have ESAH doctors and staff perform life measures on my pet in the event of an emergency, otherwise states as a DNR (do not resuscitate).

Additional services requested for my pet while at Eastern Shore Animal Hospital:

Call for prices.

Microchip Implant
Nail Trim (complimentary)
Pre-Surgical Bloodwork
Other

Other service requested:

I have read and fully understand the terms and conditions set forth above.

Electronic Signature

Date*
MM slash DD slash YYYY

Date

Phone number at which owner can be reached today or tomorrow.*

Anesthesia Consent Form