Surveypoint

Q2

Name of Pet*

Q3

Anesthetic Procedure(s) to be Performed*

Q4

Primary Phone Number*

Q5

Additional Phone Number (If I cannot be reached at the primary phone number)

Q6

Email

Q7

I authorize pre-surgical bloodwork to be run on my pet prior to anesthesia to assess organ health. I understand that this option may be required based on my pet's age or health status and will therefore be discussed with me during my pet's stay. ($93)*

Yes, I authorize.

No, I decline.

Q8

I authorize permanent identification in the form of a Home Again Microchip to be implanted in my pet while they are here for anesthesia. If your pet already has a microchip, we will not be implanting a second one. ($55)*

Yes, I authorize.

No, I decline.

Q9

I authorize post-operative laser therapy to be performed on my pet during their anesthesia recovery. If yes is selected, it will still be performed at the doctor's discretion and may not be performed. ($19)*

Yes, I authorize.

No, I decline.

Q10

I would like these additional procedures to be performed during my pet's visit. I understand these procedures may incur charges beyond what I was estimated for the original procedure.

Ear Cleaning

Nail Trim

Anal Gland Expression

Sanitary Clip

Q11

Does your pet have a history of seizures or other neurologic disorder?*

Yes.

No.

Q12

Do you have any additional concerns or questions for the anesthesia team?

Q13

First Name

Q14

Last Name

Q15

I understand that payment for this procedure and any services at Northwood Animal Hospital is required the day they are performed. I understand that an estimate is a living document and is subject to be changed throughout the day, based on new information gathered after anesthesia is achieved (such as dental radiographs, abdominal exploratory, etc). I understand that the anesthesia team will be in contact with me during the day as new conditions arise.*

I have received an estimate for the procedure(s) within the last 60 days, and understand the potential charges.

I have not received an estimate for the procedure(s), and would like one to be emailed to me. I have listed my current email address in this form.

I have not received an estimate, and I do not want one. I understand that payment for today will be required at pick-up.

Q16

By signing below with my finger or mouse, I attest that I understand the procedure to be performed on my pet and have no further questions at this time. I acknowledge there may be concealed health risks to my pet and release NAH and staff from any unforeseen complications arising from anesthesia/surgery. I will be available at the phone number(s) listed below at all times during the day of the procedure. If the doctors and staff at NAH cannot reach me by phone, I agree to allow any treatment deemed necessary for the health of my pet. *

Yes.

No.

Anesthesia Consent Form -Form Fill

Name of Pet*

Anesthetic Procedure(s) to be Performed*

Primary Phone Number*

Additional Phone Number (If I cannot be reached at the primary phone number)

Email

I authorize pre-surgical bloodwork to be run on my pet prior to anesthesia to assess organ health. I understand that this option may be required based on my pet's age or health status and will therefore be discussed with me during my pet's stay. ($93)*

I authorize permanent identification in the form of a Home Again Microchip to be implanted in my pet while they are here for anesthesia. If your pet already has a microchip, we will not be implanting a second one. ($55)*

I authorize post-operative laser therapy to be performed on my pet during their anesthesia recovery. If yes is selected, it will still be performed at the doctor's discretion and may not be performed. ($19)*

I would like these additional procedures to be performed during my pet's visit. I understand these procedures may incur charges beyond what I was estimated for the original procedure.

Does your pet have a history of seizures or other neurologic disorder?*

Do you have any additional concerns or questions for the anesthesia team?

First Name

Last Name