Name: Animal Hospital of Delhi Hills
Address: 1290 Ebenezer Road, Cincinnati, OH, 45233, United States
Telephone: 513-941-2551
Price range: $

Surgery & Anesthesia Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 513-941-2551 for a faster response.

Owner's Name *

First

Last

Pet's Name *

Age *

Breed *

Sex *

Date *

Procedure *

Primary Contact Number *

Secondary Contact Number *

Email *

Patient Status

Eaten or drank this morning?

Yes
No

Last time my pet ate was: *

Showing any signs of illness? *

Yes
No

Ever had a seizure in the past? *

Yes
No

Been diagnosed with any preexisting medical conditions? *

Yes
No

Ever had an adverse reaction to anesthesia or other medications? *

Yes
No

Current Medications

Comments

Is your pet’s preventive health care up to date? *

Yes
No

For spay/neuter procedures, is it ok to extract baby teeth? *

Yes
No

For Mass Removals

How many masses are you having removed?

Would you like the masses sent for biopsy?

Yes
No

Please sign initials

Optional Services Requested

The time during which your pet is anesthetized is a great time to perform these services.

Anal Gland Expression
Ear Cleaning
Microchip Implantation
Feline Leukemia and FIV Test

Anesthetic Consent Statement: I verify that I am the owner, or authorized agent of the owner, of the pet listed above. I authorize anesthesia and surgery/dentistry for my pet, as described above. The nature and risks of this procedure have been explained to me. I understand that some risks always exist with anesthesia, surgery, and dentistry, including death. Additionally, I authorize the Animal Hospital of Delhi Hills to perform any intervention deemed necessary for any unforeseen medical or surgical complications that may arise, and I accept full responsibility for any associated fees. If overnight hospitalization is recommended, I understand that no staff will be on the premises after hours to attend to my pet, and that

I have the option to be referred to a 24-hour facility for overnight care. I have read and understood the authorization and consent details above.

Signature of Owner/Responsible Party: *

Clear Signature

Date *

Surgery & Anesthesia Consent

Surgery & Anesthesia Consent Form

Patient Status

For Mass Removals

Optional Services Requested

Ready to visit?

Questions?

Address

Contact

Hours