Anesthesia Consent Form

At Governor Animal Clinic, your pet’s safety and comfort are our top priorities. Completing the Anesthesia Consent Form before your pet’s procedure allows our team to prepare thoroughly and ensure we have all the necessary information to provide safe, personalized care.

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How to Complete the Form

Please take a few minutes to carefully review and complete all required sections of the form prior to your pet’s procedure. Be sure to include:

  • Your contact information and preferred method of communication
  • Your pet’s current medications and medical history
  • Any known reactions to anesthesia or previous procedures
  • Emergency contact details and care preferences

Providing accurate and complete information helps our veterinarians tailor anesthesia protocols and monitoring specifically to your pet’s needs.

Complete Your Anesthesia Consent Form

Submitting your Anesthesia Consent Form in advance helps streamline your visit and allows our team to focus on delivering safe, attentive care throughout your pet’s procedure and recovery.

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Procedure Information

I, the undersigned, am the owner (or authorized agent) of the above pet and authorize Governor Animal Clinic to perform the following procedure(s): 

I understand that anesthesia will be required for this procedure. 

Anesthesia Related Considerations

Your pet will receive individualized anesthesia tailored to their health status. While modern anesthesia is generally very safe, all medical procedures carry some degree of potential complication. Our team takes extensive precautions and closely monitors your pet before, during, and after anesthesia to minimize these risks.

I have been informed that:

  • Any anesthetic procedure carries some degree of risk, including rare but serious complications such as allergic reactions, organ dysfunction, or death.
  • The staff at Governor Animal Clinic will take all reasonable precautions to reduce risks, including pre-anesthetic evaluation and monitoring.
  • Certain pre-existing health conditions may increase anesthetic risk.

Brachycephalic Breed

I have been informed that brachycephalic breeds (Bulldogs, Boxers, Pugs, etc.) have an increased risk for anesthetic complications including reflux, regurgitation, and respiratory compromise. The staff at Governor Animal Clinic will take all reasonable precautions to reduce risks, including careful selection of anesthetic protocol and may recommend medications to be given at home prior to or after the procedure.

Emergency Care

In the event of an unforeseen emergency, life-saving measures (CPR, emergency drugs) will be implemented.

Financial Agreement

I understand I am financially responsible for all services provided and payment is due at the time of discharge. 

Consent & Signature

By signing below, I confirm that I have read and fully understand this consent form. All my questions have been answered to my satisfaction.

Clear Signature

If your pet needs immediate care or you have urgent questions about their condition or procedure, please call us directly at (858) 453-6312. Online forms are not monitored for emergency situations.