(865) 523-6886
DOWNTOWN/AFTER HOURS URGENT CARE: 865.525.1167 | NORTHEAST: 865.523.6886 | CHOTO: 865.288.4630

DOWNTOWN: 865.525.1167

NORTHEAST: 865.523.6886

CHOTO: 865.288.4630

Surgical / Anesthetic Consent Form

"*" indicates required fields

Client / Authorized Agent Name*
Patient Name*
Visiting Location*
For the duration of the operation.

Additional Services

Please select below any additional services you would like to have performed at this time to reduce the need for future visits and minimize discomfort for your pet. The cost for these services is not included in the cost of the procedure. Please ask our Staff for prices.

E-Collar Policy

An Elizabethton Collar or “E-Collar” is a collar that will help prevent your pet from bothering the area and delaying the healing process. For any pet having a procedure that requires an incision, if a recovery suit or e-collar is not provided at drop off, one will be sent home with the pet. The cost is between $20-$40 depending on the size of the pet.
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Intravenous Fluids, Flea Medications, and Pain Medications

I understand that my pet will receive intravenous fluid therapy in conjunction with their anesthetic procedure today. I understand that this requires placement of an intravenous catheter, a minor procedure that will require shaving of one or more legs. Although we choose anesthetics we feel to be the safest in each case, IV fluids help improve the safety of certain surgical events. In addition, IV fluids can help speed a pet's recovery from anesthesia and help our pain control medications work more effectively. I understand that if my pet is discovered to be carrying fleas or other external parasites, he or she will be treated appropriately for such at my expense. I understand that pain control medications will be given in hospital and prescribed for post-surgical use at the doctor's discretion.
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Payment Policy

I agree to pay, in full, for services rendered including those deemed necessary for medical or surgical complications or otherwise unforseen circumstances. I understand that any provided estimate of fees for presently planned procedures is only a best approximation, and the the final bill may be less or greater than this estimated amount. Should I fail to pay for any services provided, I will be responsible for all service charges and collection fees.
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Pre-Anesthetic Bloodwork

Many health problems cannot be identified by a physical exam, therefore we do require, at the Veterinarian's discretion that all pets receive a preanesthetic blood screen to help determine the presence of internal illness that may cause complications with anesthesia. This screening does not guarantee the absence of potential complications, but does greatly reduce the risk of complications and helps identify health conditions that may require medical treatment in the future. The cost of the preanesthetic panel and CBC is $95. Please initial the box that you understand the required blood work.
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Hours of Operation and Staffing

I understand that CVH is open and fully staffed only during the hours of 7am to 7pm on weekdays and 7am to 1pm on Saturdays, excluding major holidays. I further understand that staff members do come in to take care of the patients in the hospital on Sundays and holidays, but that the hours of staffing may be even more limited than those listed above and that visiting, intake, and discharge are not permitted during these times. I understand that this means that my pet may not be monitored during the times the hospital is closed and release CVH from any and all liability due to circumstances that may arise while the hospital is closed. I understand that there are multiple nearby facilities that are open either 24 hours a day or during the times that CVH is closed and wish for my pet to stay at CVH instead of being transferred to one of these facilities during these times. Additionally, I understand that CVH and its employees do not provide transportation for patient transfers. In the event that my pet requires transfer to another facility for emergency care, specialized treatment, or any other reason, I accept full responsibility for arranging and facilitating transportation, either personally or through an authorized agent. While CVH will make every reasonable effort to assist and advise me, I acknowledge that the responsibility for timely and safe transfer rests with me or my designated representative.
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Resuscitation Status

I understand that the doctors and staff of CVH will take all reasonable precautions to ensure the safety of my pet but that adverse events, up to and including death, are possible with anesthesia. In the case that my pet goes into cardiac arrest while under the care of CVH, I approve the use of all reasonable measures to resuscitate my pet. These may include, but are not limited to, CPR, injectable medications, and oral/parenteral medications. I understand that the doctors of CVH will determine what measures are reasonable and at what point such measures should be discontinued. I agree to be held responsible for the costs associated with any resuscitation attempt that is made on my pet.
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Statement of Commitment

The staff of Central Veterinary Hospital (CVH) assures you that we will use our best judgment in caring for your pet. This judgment is based on experience, the physical exam of your pet, and any laboratory analysis you authorize.
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