Your Name *

First

Last

Pet Name *

Procedure *

Date *

Your pet’s safety and comfort are our main concern at Bel-Aire Veterinary Hospital. Before your pet has surgery today, he/she will be examined for any problems that could interfere with anesthesia and will be monitored during recovery to help ensure that all goes well. We are proud to report that our patients do very well and we expect his/her surgery to go smoothly.

Procedures requiring anesthesia are always associated with a certain amount of risk, whether the patient is a person or a pet. Like you, we want to minimize that risk as much as possible. This requires a physical evaluation and pre-anesthetic testing. General anesthesia has become safer in recent years with the advent of newer drugs and better patient monitoring. Some conditions may not, however, be evident on a physical exam. To better ensure your pet’s safety during anesthesia, we advise the following pre-anesthetic tests be performed, even for elective procedures such as a spay, declaw, and castration. Sometimes we adjust the anesthesia used or alter the procedure to make it safer for your pet. Occasionally, we postpone the surgery until a medical problem has been resolved.

Perform pre-anesthetic testing for my pet (Required for pets over 6 years old) *

Yes
No

Microchip implant *

Yes
No

Perform K Laser Therapy on my pet *

Yes
No

For Dental Cleanings, if the doctor feels that extractions are needed, do we have your consent? *

Yes
No

I.V. fluids prior to and during procedure *

Yes
No

Cerenia Injection (for nausea post-op) *

Yes
No

Additional Cost: 0-29lbs
30-50lbs
51-75lbs
76-100lbs
101-140lbs

Has your pet eaten since 12 midnight? *

Yes
No

Is your pet currently on any medcation? *

Yes
No

Please list: *

CPR/DNR Consent

Bel-Aire Veterinary Hospital is committed to providing patients with the care that considers the quality as well as the quantity of a pet’s life. For patients experiencing advanced disease, advanced age, multiple disease processes, or a disease considered to be terminal, it is appropriate to decide in advance whether aggressive measures of resuscitation (CPR) will be employed if needed. DNR means “do not resuscitate”. This is a decision that resuscitation (CPR) is not to be performed if the pet stops breathing, has no heartbeat, collapses, or becomes unconscious. Resuscitation (CPR) of a collapsed or unconscious patient is tailored to meet the needs of the individual pet but may include any or all of the following:

Establishing an airway via insertion of an endotracheal tube and administration of oxygen or medications through the tube
Establishing intravenous access via insertion of an intravenous catheter and administration of fluids and injectable medications through the catheter
Chest compressions
Intracardiac delivery of injectable medications

Animals that have survived cardiopulmonary arrest and have been successfully resuscitated (CPR) are extremely critical and unstable. Management of the post-arrest patient requires vigilant monitoring and the technical expertise of dedicated critical care personnel. This care is costly, and the outcome is uncertain.

DNR I DO NOT wish the staff to perform CPR on my pet. I understand that if my pet suffers from cardiac arrest, respiratory arrest, collapse, or unconsciousness if CPR is not performed, my pet will pass away. *

Yes, I understand

Signature of Owner/Agent *

CPR I wish the staff to perform resuscitation (CPR) on my pet if my pet suffers from cardiac arrest, respiratory arrest, collapse, or unconsciousness. I accept that if the hospital staff is unable to reach me within 20 minutes after the initial CPR procedures, and after exercising reasonable medical judgment, determine that there is no hope for success, the staff will cease further CPR procedures. I understand that despite the best effort of the veterinarians and staff at this facility, even the most successful CPR that may restore my pet’s life may not allow for my pet to regain his/her normal mental and physical health. If I request such emergency procedures, I agree to be held responsible for veterinary services provided to my pet while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me. *

Yes, I understand

Signature of Owner/Agent *

I have read and understand the information above or have had it explained to my satisfaction. I understand that the anesthetic, surgical or therapeutic procedures and treatments my pet is undergoing today may involve the risk of complications, injury or even death, from both known and unknown causes and no warranty or guarantee has either been expressed or implied as to the result or cure. I agree to release Bel-Aire Veterinary Hospital, Inc, and its agents and representatives, from liability for all damages to my pet and agree to hold its agents and representatives harmless from any liability (except in the case of gross negligence) associated with the procedure and treatments being performed on my pet. I hereby authorize and direct Bel-Aire Veterinary Hospital to perform the procedure(s) noted above as deemed advisable for my pet. *

Yes, I have read and understand.

Signature of Owner/Agent *

Phone Number *

Date *

Bel-Aire Veterinary Hospital Representative

Welcome to Bel-Aire Veterinary Hospital. Your Veterinarians in Greensboro, NC. Call us at (336) 665-1286

Surgery Consent Form

Surgery Consent Form

CPR/DNR Consent

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