Surgery & Anaesthesia Consent Form

This form explains the procedure your pet is scheduled to undergo, the risks involved, and the decisions we need from you before we begin. Please read each section carefully and ask our team if anything is unclear.

Section 1 — Patient & Procedure

Weight on day of surgery:

Scheduled procedure:

Attending veterinarian:

Section 2 — Pre-Surgical Fasting

To reduce the risk of vomiting and aspiration under anaesthesia, dogs and cats should not eat solid food after midnight the night before surgery. Water is usually fine until drop-off. Rabbits, guinea pigs, and small exotics should NOT be fasted — please confirm with our team.

I confirm my pet followed the fasting instructions provided by the clinic.

Time of last meal / water:

Section 3 — Anaesthesia Risk Acknowledgment

Anaesthesia is necessary for safe surgery but carries inherent risk, which is increased in senior pets, brachycephalic (flat-faced) breeds, and patients with underlying disease. Our team will monitor heart rate, respiration, oxygen saturation, blood pressure, and temperature throughout the procedure.

I understand anaesthesia carries risk and that no outcome can be guaranteed.

I understand my pet may be brachycephalic or otherwise higher-risk and consent to the anaesthesia plan.

I consent to pre-anaesthetic bloodwork to screen for hidden problems.

I decline pre-anaesthetic bloodwork and accept the additional risk.

I consent to IV fluids during the procedure to support blood pressure and organ perfusion.

Section 4 — Optional Add-On Services

While your pet is under anaesthesia we can often perform additional services more safely and economically. Please indicate whether you would like any of the following:

Microchip implantation

Anal gland expression

Retained baby tooth extraction (if found)

Submit any removed mass for histopathology (biopsy)

Section 5 — Resuscitation Preferences

In the unlikely event of cardiac or respiratory arrest, please indicate your preference. CPR in veterinary medicine has roughly a 5–10% success rate and can result in rib fractures or neurological damage even when successful.

Full CPR — chest compressions, intubation, emergency drugs (additional fee applies)

Closed-chest CPR only (no open-chest massage)

Do Not Resuscitate (DNR) — allow a peaceful passing

Section 6 — Reaching You During the Procedure

Best phone number during surgery:

Secondary number if we cannot reach you:

If we discover something unexpected during surgery and cannot reach you, please indicate your preference:

Use your best clinical judgment; I trust the veterinarian to proceed.

Stop and wake my pet up; call me before doing anything additional.

Section 7 — Authorisation

I have read and understood this form and authorise the procedure and anaesthesia described above.

Thank you for trusting us with your pet. We will call you as soon as the procedure is complete.

Authorized representative — printed name:

Signer — printed name:

Surgery & Anaesthesia Consent Form

Section 1 — Patient & Procedure

Weight on day of surgery:

Scheduled procedure:

Attending veterinarian:

Section 2 — Pre-Surgical Fasting

I confirm my pet followed the fasting instructions provided by the clinic.

Time of last meal / water:

Section 3 — Anaesthesia Risk Acknowledgment

I understand anaesthesia carries risk and that no outcome can be guaranteed.

I understand my pet may be brachycephalic or otherwise higher-risk and consent to the anaesthesia plan.

I consent to pre-anaesthetic bloodwork to screen for hidden problems.

I decline pre-anaesthetic bloodwork and accept the additional risk.

I consent to IV fluids during the procedure to support blood pressure and organ perfusion.

Section 4 — Optional Add-On Services

While your pet is under anaesthesia we can often perform additional services more safely and economically. Please indicate whether you would like any of the following:

Microchip implantation

Anal gland expression

Retained baby tooth extraction (if found)

Submit any removed mass for histopathology (biopsy)

Section 5 — Resuscitation Preferences

Full CPR — chest compressions, intubation, emergency drugs (additional fee applies)

Closed-chest CPR only (no open-chest massage)

Do Not Resuscitate (DNR) — allow a peaceful passing

Section 6 — Reaching You During the Procedure

Best phone number during surgery:

Secondary number if we cannot reach you:

If we discover something unexpected during surgery and cannot reach you, please indicate your preference:

Use your best clinical judgment; I trust the veterinarian to proceed.

Stop and wake my pet up; call me before doing anything additional.

Section 7 — Authorisation

I have read and understood this form and authorise the procedure and anaesthesia described above.

Thank you for trusting us with your pet. We will call you as soon as the procedure is complete.

Authorized representative — printed name:

Signer — printed name:

Veterinary Clinic

Surgery & Anaesthesia Consent Form

Section 1 — Patient & Procedure

Section 2 — Pre-Surgical Fasting

Section 3 — Anaesthesia Risk Acknowledgment

Section 4 — Optional Add-On Services

Section 5 — Resuscitation Preferences

Section 6 — Reaching You During the Procedure

Section 7 — Authorisation

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Surgery & Anaesthesia Consent Form

Section 1 — Patient & Procedure

Section 2 — Pre-Surgical Fasting

Section 3 — Anaesthesia Risk Acknowledgment

Section 4 — Optional Add-On Services

Section 5 — Resuscitation Preferences

Section 6 — Reaching You During the Procedure

Section 7 — Authorisation

About this template

What's in this template

Frequently asked questions

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