Anesthesia Release

I hereby entrust Oswego Veterinary Hospital (OVH) 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 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.

Our surgery team takes every precaution to ensure the safety of your pet, and while complications from anesthesia and/or surgery are rare, they are not impossible. I understand that potential complications include but are not limited to death, blindness, dehiscence or infection of incisions, or progression of underlying heart, kidney, or liver disease.

CPR/DNR Consent:
In the unlikely event that the above-named pet should experience cardiac or respiratory arrest while being hospitalized today, we need to know, in advance, what your wishes are for your pet. If your pet does experience anesthetic difficulty, cardiac or respiratory arrest, we will contact you as quickly as possible. However, your pet's safety and well-being come first, so we need you to direct us here as to your wishes for their care.

Definition of Cardiopulmonary Resuscitation (CPR):
All resuscitative efforts are to be attempted to restore normal heart function and to breathe as deemed necessary by the doctor until I can be reached. Should my pet require cardiopulmonary resuscitation (CPR), I request that the doctor(s) pursues medical care. I understand that this is a cost in ADDITION to any estimate, and I agree to pay this fee. The cost of full CPR is typically at least an additional $300 or more and in no way guarantees that my pet will survive their cardiac or respiratory event. Patients who require CPR typically need at least 24 to 48 hours of intensive care and monitoring at a specialty facility following resuscitation. It will be necessary for me to transport my pet to the specialty facility and I will be responsible for the charges for my pet's care at that facility. Additionally, often, pets who receive life-saving CPR do not return to normal functionality.

Definition of Do Not Attempt Resuscitation (DNR):
No cardiopulmonary resuscitation (CPR) efforts will be performed in an effort to save my pet if they have cardiac or respiratory arrest, only the administration of medication to help ease my pet's passing may be used.

Please select the option you'd like the doctors to proceed with. *

I agree to CPR being performed in case of arrest. However, if CPR has been performed for 10 minutes, I have not been able to yet be reached by either phone number listed above, and my pet is unable to support cardiac or respiratory function on their own, I authorize the doctor on duty to make the decision to discontinue CPR which may result in my pet's death.
I elect a “Do Not Resuscitate” status in case of arrest. If my pet is actively suffering during its cardiac and/or respiratory arrest, the doctor may give a euthanasia solution to ease its passing.

ADDITIONAL TREATMENT DIRECTIVE

I understand the nature of today’s surgery based on the treatment plan provided previously by OVH and conversations with the doctor and/or surgical staff. *

I have read and understand.

I understand an IV catheter will be placed in my pet’s leg to administer fluids and medications, and that my pet's hair will be shaved at the site of the IV catheter, as well as at the site of any surgical or monitoring equipment. *

I have read and understand.

Patient Name *

Name of contact person *

First

Last

This person is: *

Owner
Authorized Agent

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. We will use this phone number for all requested communications unless otherwise specified. Please provide a phone number below. *

I have read and understand.

Phone *

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: *

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 *

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 be notified when your pet is about to undergo anesthesia? *

Yes, via text
Yes, via a phone call
No, I do not need to be notified when my pet is about to be anesthetized.

Please list phone number to text if different than above:

Please list phone number to call if different than above:

Would you like to be notified when your pet wakes up from anesthesia? *

Yes, via text
Yes, via a phone call
No, I do not need to be notified when my pet wakes up

Please list phone number to text if different than above:

Please list phone number to call if different than above:

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. *

I have read and understand.

Signature *

Printed Name *

First

Last

Today's Date *

PRE-ANESTHESIA QUESTIONNAIRE

Please complete no later than 4pm on the day prior to your pet’s procedure.

My pet is a:

Dog/Cat
Bird/Rabbit/Rat/Other Pocket Pet

Dog/Cat Questionnaire

I agree to feed no more than ¼ of my pet’s regular meal on the morning of surgery: *

Yes
No - if selected, please contact us immediately at 503-636-3001

Is your pet on any medications? *

Yes
No

If yes, please list the name of medication(s) and when the last dose was given. If you have questions as to whether your pet should receive medications on the morning of surgery, please call us at 503-636-3001. *

Has your pet been ill recently? *

Yes
No

If so, please describe the symptoms and indicate date/time of last symptoms: *

Does your pet have an ID Microchip? *

Yes
No
I’m not sure

If no, would you like one placed during your patient’s procedure today? *

Yes
No

Would you like your pet to have a complimentary nail trim while anesthetized? *

Yes
No

Do you need any medications refilled? *

Yes
No

If yes, please list the medication you need refilled. *

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)?

  Bird/Rabbit/Rat/Other Pocket Pet Questionnaire

I have been informed NOT to fast my pet prior to anesthesia and will bring some of my pet’s food to their surgical appointment: *

Yes
No

Please contact us immediately at 503-636-3001

Is your pet on any medications? *

Yes
No

If yes, please list the name of medication(s) and when the last dose was given. If you have questions as to whether your pet should receive medications on the morning of surgery, please call us at 503-636-3001. *

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

If so, please describe the symptoms and indicate date/time of last symptoms: *

Would you like your pet to have a complimentary nail trim while anesthetized?

Yes
No

Do you need any medications refilled?

Yes
No

If yes, please list the medication you need refilled. *

Is your pet on a prescription or special diet? *

Yes - If yes, please bring some of their own food with you to check in.
No

Do you have a cone for your pet? *

Yes - If yes, please bring with you to check in.
No

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)?

IS YOUR PET’S PROCEDURE A DENTISTRY AND/OR INCLUDE A DENTISTRY?

Yes
No

I, the undersigned owner or owner's agent of the pet named above, have been informed that my pet is in need of preventive or therapeutic dental care and consent to the procedures described to me by staff veterinarians at Oswego Veterinary Hospital and outlined in my pet's treatment plan. These procedures include but are not limited to the following:
• Dental radiographs
• Dental prophylaxis (Comprehensive oral evaluation, teeth cleaning and polishing)
• Extractions
• Gingival flap surgery to close extraction sites
• Antibiotic gel implants
• Removal of gingival or soft tissue growths. If the veterinarian determines that your pet requires any procedures beyond radiographs and prophylaxis:

I, the undersigned owner or owner's agent of the pet named above, have been informed that my pet is in need of preventive or therapeutic dental care and consent to the procedures described to me by staff veterinarians at Oswego Veterinary Hospital and outlined in my pet's treatment plan. These procedures include but are not limited to the following: 1. Dental radiographs 2. Dental prophylaxis (Comprehensive oral evaluation, teeth cleaning and polishing) 3. Extractions 4. Gingival flap surgery to close extraction sites 5. Antibiotic gel implants 6. Removal of gingival or soft tissue growths. If the veterinarian determines that your pet requires any procedures beyond radiographs and prophylaxis:

I prefer that you proceed with all necessary dental procedures, even if the cost may exceed the signed treatment plan
I prefer to be contacted before any procedures beyond radiographs and prophylactic cleaning are performed, with the exception of emergency care.

IF I CANNOT BE REACHED IN A TIMELY MANNER:

I authorize the veterinarian to proceed with the procedures they deem necessary for my pet and will be responsible for the costs associated with those procedures.
I do not authorize any extractions or dental procedures, even if the veterinarian deems them medically necessary. I am aware that this means infected or diseased teeth will be left untreated and will likely require a subsequent anesthetic dental procedure that will need to be scheduled in the future at my expense.

I understand that all accounts are payable at the time of discharge unless a prior arrangement has been made.

I have read and understand.

Signature *

Date: *

Fill out this form prior to your pet’s procedure.

ADDITIONAL TREATMENT DIRECTIVE

PRE-ANESTHESIA QUESTIONNAIRE

We love new clients!

Location

Hours

Contact Us

Have a question?

Learn more about our services!