Anesthesia Consent Form

I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the animal
listed above. I authorize the Veterinarian(s) and staff of Strong Veterinary Hospital to perform the
procedure(s) listed above and/or on the estimate for my animal. I authorize the use of anesthesia
and other medication as deemed necessary by the veterinarian and understand that hospital
personnel will be employed in the procedure(s) as directed by the veterinarian.

Strong Veterinary Hospital offers the safest anesthetic and surgical procedures available for your
pet, however, there is always an element of risk with any anesthetic procedure, and occasionally
problems may occur during or after any medical or surgical procedure. Therefore, I hereby
consent to and authorize the performance of such procedures as are necessary in the exercise of
the veterinarian’s professional judgement. I also do hereby acknowledge that I understand that
there are no guarantees either expressed or implied that the procedures authorized will be
without complications from unexpected events beyond the veterinarian’s and hospital’s control.

In the unforeseen event that emergency intervention is warranted, initial emergency medical
management and stabilization may include, but is not limited to the following treatment and
diagnostics: Cardio-Pulmonary Resuscitation (CPR), bloodwork, radiographs, oxygen therapy and
medication administration. An estimated cost for life saving measures can range from $250 –
$500.Please select ONE option regarding emergency treatment:

Flea control is particularly important for your hospitalized pet and our hospital. Should we
discover that your pet has fleas or evidence of fleas, they will be treated according to their
weight. In this manner, we can ensure the transmission of parasites is prevented between
animals and we maintain a flea-free hospital environment. If we must treat your pet for fleas,
there will be an additional cost added on to the invoice for that treatment.

If you decide to leave personal items at the hospital while your pet is undergoing a procedure
(i.e., leash, collar, harness, etc.), Strong Veterinary Hospital will not be responsible for any lost
items.

I have read and understand this form and accept responsibility for payment of all charges
incurred and services provided to my animal by Strong Veterinary Hospital.