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GreenTree Animal Hospital

Surgery & Anesthesia Consent Form

Thank you for choosing us! Please fill out the following form before your scheduled appointment.

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Surgery & Anesthesia Consent Form

Please note: All * fields are required. If you have any questions, please call us at 847-680-6543.

Client Name *

First

Last

Email *

Patient Name *

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

Additional number

After procedure:

Would you like us to text you after the procedure, or would you prefer a call? *

Text
Call

Anesthetic and surgical procedure(s) to be performed: *

I, the undersigned owner or agent of the pet identified above, authorize the staff of GreenTree Animal Hospital to perform the above procedure(s). *

I have read and agree

I authorize the attending veterinarian to administer an appropriate anti-anxiety medication to alleviate fear, anxiety, or stress my pet might be indicating during their hospital stay. *

I authorize
I do not authorize

Pre-anesthetic blood test: No surgery is without risk, however small; thus, we will perform a pre-anesthetic blood profile to check the blood count, protein level, and kidney & liver function. Our hospital is equipped to perform these tests, and the doctor will have the results prior to anesthesia induction. If an abnormality arises, the doctor will contact you and discuss the steps necessary to ensure your pet’s safety before, during, and after his/her procedure. Some patients may have had blood work done in the previous 6-8 weeks. The doctor will determine if the blood work will be viable for today’s procedure. Tests are as follows: *

Routine anesthesia/surgery for pets younger than 6 years old
Routine anesthesia/surgery for pets older than 6 years old
Blood work has already been completed

Date Bloodwork was Performed *

Pre-operative ECG: An ECG is recommended for dogs and cats prior to general anesthesia as part of the pre-anesthetic work-up to screen underlying heart diseases and abnormalities. I would like my pet to receive an ECG *

Yes
No

Intravenous Catheterization: For the best possible care and safety for your pet, we will place an intravenous catheter and provide maintenance fluid therapy during & after the surgery or procedure. The catheter helps to prevent dehydration that could occur when food and water is withheld for the day and provides for the immediate access to your pet’s circulatory system in case emergency fluids or medications are needed. *

Yes
No

I understand that during the performance of the operation, unforeseen conditions may arise that may necessitate an extension or change of the above procedure(s). Therefore, I consent to the performance of such procedure(s) that the veterinarian deems necessary and in the best interest of my pet. I also authorize the use of appropriate anesthetics and/or medications, and I understand the hospital support personnel will be employed under the authority of the veterinarian and that the results cannot be guaranteed. *

I have read and understand

Microchip: *There is an additional fee for this procedure* *

Yes
No
Already has one

Nail Trim: Would you like a complimentary nail trim for your pet? *

Yes
No

Have you given your pets any medications or supplements in the past week? *

Presurgical Pack
Carprofen
Meloxidyl
Other (please specify below)
None

Other medication(s), please specify and note last time given

When was the last time fed?

Any other concerns/allergies/procedures?

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. *

I have read and agree

I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life sustaining procedures. *

I give my permission [yes]
I do not give my permission [no]

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. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree

Please Sign Here *

Date *

Phone

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Email

[email protected]

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Address

800 E. Park Ave (Rt. 176)
Libertyville, IL, 60048

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Hours of Operation

Mon, Tues, Thurs, Fri: 8:00 am - 6:00 pm

Wed: 8:00 am - 2:00 pm ; 3:00 pm - 7:00 pm

Sat: 8:00 am - 12:00 pm

Sun: Closed

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Hours of Operation

Mon, Tues, Thurs, Fri:
8:00 am - 6:00 pm

Wed:
8:00 am - 2:00 pm
3:00 pm - 7:00 pm

Sat:
8:00 am - 12:00 pm

Sun:
Closed

Have A Question?

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Email *

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How can we help you? *

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