714-587-4888 Reception@TLAH-vet.com

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Anesthetic Consent

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Anesthetic Consent Form

Please fill out this form as completely and accurately as possible before your visit.

Client Name(Required)

First Last

Email(Required)

Patient Name(Required)

Phone number at which owner can be reached today or tomorrow:(Required)

Additional number

Before Procedure:

Would you like to be contacted before your pet goes in for the procedure(Required)

Yes

No

Would you like to be contacted by text or phone call before the procedure?(Required)

Yes

No

If text, what number would you like to be texted at?

After procedure:

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

Text

Call

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

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

I have read and agree

Microchip: *There is an additional fee for this procedure*(Required)

Yes

No

Already have one

Have you given your pets any medications or supplements in the past week? (Required)

Yes, Presurgical Pack

Yes, Other medication(s), please specify below

No

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

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.(Required)

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.(Required)

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.(Required)

I have read and agree

Digital Signature(Required)

Date(Required)

MM slash DD slash YYYY

Comments

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

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15100 Kensington Park Dr.
Ste 520
Tustin, CA 92782

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Phone: (714) 587-4888
Fax: (714) 684-6994

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Reception@TLAH-vet.com

Please text or call us about your pet, we are unable to respond to emails about patients at this time.

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Mon–Fri: 8am–6pm

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Holiday Closures:

New Year’s Day
Memorial Day
Independence Day (July 4th)
Labor Day
Thanksgiving Day
Day after Thanksgiving (Nov 24th)
Christmas Eve, Christmas Day, Boxing Day (Dec 24th-26th)
New Year’s Eve

Questions?

Please allow us 24 hours to get back to your request.

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First Last

Email(Required)

Phone

How can we help you?(Required)

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Comments

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

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