Name *

First

Last

Email *

Cat's Name *

My cat has been scheduled for the following procedure(s): *

Contact Information

Phone number where I can be reached on the day of my cat's procedure: *

Preferred method of contact: *

Text
Phone Call

Emergency Contact: Please provide the name and phone number of a person authorized to make medical decisions on your behalf in the event that we cannot reach you at the phone number listed above.

Emergency Contact Name: *

First

Last

Phone Number: *

Patient Information

Approximate Age *

Breed (if known) *

Fur Color(s) *

Gender *

Has your cat been spayed (female) or neutered (male)? *

Yes
No
Don’t know

Does your cat receive any medications or supplements on a regular basis? If so, please list all medications below and when your cat last received them. *

Has your cat experienced any unreported illness or injury in the past 90 days? *

Yes
No

Please describe. *

Has your cat experienced any complications or adverse effects associated with anesthesia or sedation in the past? *

Yes
No

Please describe. (copy) *

May we offer your cat a light meal later today after the procedure? *

Yes
No

Please list any dietary restrictions. *

Would you like your cat to have a complimentary toe nail trim while he/she is anesthetized or sedated? *

Yes
No

Anything else you’d like us to know:

Please read the following statements, then sign below.

I understand that anesthesia services are needed so that my cat’s doctor can perform the procedure(s) listed above. It has been explained to me that all forms of anesthesia involve some risks and no guarantees or promises can be made concerning the results of my cat’s procedure or treatment. *

I have read and understand

I understand that, although rare, severe unexpected complications can occur with each type of anesthesia, including but not limited to the possibility of infection, bleeding, drug reactions, blood clots, loss of sensation, loss of vision, loss of limb function, paralysis, brain damage, or death. *

I have read and understand

I understand that these risks apply to ALL forms of anesthesia and that additional or specific risks have been identified for the specific types of anesthesia listed below. *

I have read and understand

I understand that the type(s) of anesthesia used will be determined by many factors including my cat’s physical condition, the type of procedure, the length of the procedure, and/or the doctor’s preference. *

I have read and understand

It has been explained to me that sometimes an anesthesia technique that involves the use of local anesthetics and/or sedation may not succeed completely and therefore another technique may have to be used, including general anesthesia. *

I have read and understand

Anesthesia Technique	Expected Result	Technique	Risks Include but are not Limited to:
General Anesthesia	Completely unconscious state, does not respond to external stimuli or feel pain	Drugs are injected into the bloodstream, and a tube is placed in the windpipe to administer oxygen and anesthetic gas	Hoarseness (sore throat), injury to trachea, injury to blood vessels, vomiting, aspiration, pneumonia
Sedation	Semi-conscious state, reduced anxiety and pain	Drugs are injected into the bloodstream or into the muscle, oxygen is provided by face mask or by holding the oxygen tubing close to the patient’s the face	An unconscious state, depressed breathing, injury to blood vessels, vomiting, aspiration, pneumonia
Locoregional Anesthesia	Temporary loss of feeling and/or movement in a particular location or region of the body	Drugs are injected near nerves or placed directly into the surgical site, providing loss of sensation in the local area	Infection, weakness, persistent numbness, residual pain (requiring additional anesthesia)

I consent to the anesthesia services indicated, and I authorize that they be administered by Whitney Odom, DVM, and/or her agents. I also consent to an alternative type of anesthesia, if necessary, as deemed appropriate. *

I have read and consent

In the event of an emergency, the doctor and/or her agent will attempt to contact me at the phone number listed above. If they cannot reach me, I would like the doctor and/or her agents to do the following (choose ONE): *

Perform any additional diagnostic or therapeutic procedures necessary to treat my cat and maintain my cat’s health and comfort. I expect the doctor and/or her agents to use reasonable precautions to ensure my cat’s safety, and I agree to pay in full for all services provided when my cat is discharged.
I do not authorize any additional diagnostic or therapeutic procedures beyond what is stated in the Treatment Plan. I understand that delaying necessary treatment could be harmful to my pet.

In the event that my cat stops breathing or his/her heart stops beating, I request that the doctor and staff of Atrium Cat Hospital pursue such medical care as indicated below (choose ONE): *

I request that cardiopulmonary resuscitation (CPR) be performed in the event that my cat stops breathing or his heart stops beating.
I request that CPR NOT be performed in the event that my cat stops breathing or his heart stops beating. I understand that this will result in the death of my cat.

I acknowledge that I have read this form, that I understand the risks, alternatives and expected results of the anesthesia service and that I had ample time to ask questions and to consider my decisions. *

I have read and agree.

Signature *

Date *

Consent for Anesthesia Services