To ensure the safety of all of our patients and staff, an up-to-date Rabies Vaccination is required at our clinic.

763-753-6336

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Home » Anesthesia and Surgical Consent Form

Anesthesia and Surgical Consent Form

Oak Grove Animal Hospital
19035 Lake George Blvd
763-753-6336

Client's First Name(Required)

Client's Last Name(Required)

Pet's Name(Required)

As the owner or authorized representative of the owner of the pet, I give permission for the following surgery or treatments:

Please fill in the box with the treatment or surgery to be performed(Required)

Please select any additional procedures that will be performed(Required)

E-collar Cone

Vaccines

Heartworm Test $68

Microchip $70

Histopathology $201

Decline

Please select which vaccines requested(Required)

Rabies

Distemper

Lyme

Leptospirosis

Bordetella

Feline Leukemia

Decline

Current Medication

Last Given

Please explain any additional concerns or notes you'd like us to be aware of.

Recommended Services

IV fluids- The IV catheter provides quick access to a vein in case of an emergency and assists in maintaining blood pressure. IV fluids may be required by the veterinarian on a case-by-case basis and is required for pets over the age of seven.(Required)

I decline IV fluids during the above procedure

I elect IV fluids during the above procedure (required for pet over age 7 and all dental procedures)- $120

Pre-anesthetic blood panel- We highly recommend a pre-anesthetic screening . A pre-anesthetic screening maximizes the patient's safety and alerts the doctor to the presence of dehydration, anemia, infection, diabetes and/ or kidney or liver disease that could complicate the procedure. This may be required by the veterinarian on a case by-case basis and is required for pets over the age of seven.(Required)

I decline pre-anesthetic screening

I elect a Chemistry and Complete Blood Count (required for pet over age 7 and all dental procedures) -$218.50

Consent for CPR

Should my pet require CPR, including compression, positive pressure respiration, emergency drugs, and/or any other life-saving interventions, I request that the doctor at this hospital pursue such medical care.(Required)

I approve of having any life-saving procedures performed on my pet. I agree to be held responsible for all costs for services performed while staff members pursue treatments. Regardless of my pet’s survival, I agree to be held responsible for a minimum resuscitation fee of $100 in addition to any further fees already identified by the practice and agreed upon by me.

I decline to have any life-saving procedures as outlined above including, but not limited to CPR and the use of emergency drugs. No person shall attempt to resuscitate my pet. I voluntarily execute this order and fully understand it.

Authorization and Risk Assessment

Electronic Consent(Required)

I agree

I hereby authorize the doctors and staff at Oak Grove Animal Hospital to care for my pet. I consent to the use of anesthesia and/or sedation under the direction of the veterinarian. I understand that during the performance of this procedure, unforeseen conditions may be revealed that could result in a change to the procedures set forth above. I expect Oak Grove Animal Hospital to use reasonable care and judgment in performing the procedures. The nature of the requested procedures and risks involved have been explained to me and I realize results cannot be guaranteed.

Client’s Primary Phone Number(Required)

Client’s Secondary Phone Number

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Pick-up Time(Required)

To Be Filled Out By Staff

Checked in by _____________________________ on _______/_______/________

This field is for validation purposes and should be left unchanged.

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Business Hours

Monday

7:30am - 5:30pm

Tuesday

7:30am - 5:30pm

Wednesday

7:30am - 5:30pm

Thursday

7:30am - 5:30pm

Friday

7:30am - 5:30pm

Saturday

8:00am - 12:00pm

Sunday

Closed

763-753-6336

19035 Lake George Blvd,
Oak Grove, MN 55303

Make an Appointment

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