Pre-Anesthesia Consent Form

Client/Patient Info


Owner's Name (*)

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Email (*)

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Date (*)

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Pet's Name (*)

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Species (*)

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Client Number

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Breed (*)

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Color

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Age

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Consent Info


Like you, our greatest concern is the well being of your pet. Prior to administering anesthesia to your pet, a full physical exam is performed. Included in the price of each procedure is: (1) an intravenous catheter and fluid therapy, (2) pain medication before, during, and after the procedure, (3) state of the art anesthesia monitoring.
Pre Anesthetic Blood Testing (*)
A blood analysis can reveal underlying problems that may not be outwardly visible. This test provides us with a look at your pet’s vital organ function which can play a critical role in determining how much risk is involved. Before administering any anesthetic, a doctor will evaluate these test results.

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Microchipping (*)
30-40% of all pets will get lost in their lifetime. We recommend all pets be permanently identified through the use of a microchip implanted under the skin. This quick and simple procedure gives your pet permanent identification that will assist in the return of your pet if found and scanned by and animal shelter or veterinary hospital. ($45, includes registration through HomeAgain)

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Primary Contact Number (*)

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Alternate Contact Number (*)

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I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above and have the authority to execute this consent.

I understand that during the performance of the procedure, an unforeseen situation may arise that necessitates an extension or variance in the procedure set above. I hereby authorize Centennial Hills Animal Hospital to use reasonable care and judgment in performing the procedure.

I have been advised as to the nature of the procedures and the risks involved in performing general anesthesia to the above described animal. I realize that results cannot be guaranteed.

I have read and understand this authorization and consent. I further understand that I assume financial responsibility for all services rendered.

PAYMENT IS DUE IN FULL AT THE TIME OF SERVICE I am the owner or authorized agent of the pet(s) mentioned and accepts full responsibility for all costs incurred. I understand that as a condition of treatment by this hospital, any financial arrangements must be made in advance. In the event that this account should go unpaid, I will be subject to the cost of collections, including attorney fees and/or collection agency fees, which may include charges of up to 50% of my unpaid balance. There is a 15% finance charge applied to all balances over 30 days, and a $7.50 billing charge on all balances which is applied at the end of each month. Certain procedures and services may require a deposit (cash or credit card only), with the remaining balance paid in full at the time of release. For your convenience, we also accept the following forms of payment: CASH, VISA, MASTERCARD, DISCOVER

By pressing the submit button, I, the owner of the above pet, agree to all of the above statements.

“We have been happy with every service received here, from routine rabies shots to emergency surgery.”