Exotic Mammal Anesthesia & Surgery Consent

Owner's Name:

Patient's Name:

Preferred Phone Number:

Has Your Pet Had any Illness or Injury in the Past 30 Days?

Yes No

Any History of Seizures?

Yes No

Any History of Previous Anesthetic Problems?

Yes No

Any Allergies to Medications?

Yes No

If Yes, Please List:

Current Medications, Including When Last Given:

Previously Diagnosed Medical Conditions Not Listed (If Applicable)?

I the undersigned owner or agent of the owner of my pet, certify that I am eighteen years of age or over and authorize the veterinarian(s) at FloridaWild Veterinary Hospital to perform the above procedure(s). I understand that some risks always exist with drug therapy and medical treatments and I have been encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. By submitting this form, it indicates that any questions I have regarding the following issues have been answered to my satisfaction:

The reasonable medical treatment options for my pet
Sufficient details of the procedures to understand what will be performed
How fully my pet will recover and how long it will take
The most common and the most serious side-effects
The length and type of follow-up care and home care required
The estimate of the fees for all services
Any necessary payment arrangements

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.

Should unexpected life-saving emergency care be required and the hospital staff is unable to reach me:

the staff has my permission to provide such treatment. I agree to pay for such services and understand that those fees are not included in my estimate.

the staff does not have my permission to provide such treatment.

I understand that during the performance of medical, surgical, or anesthetic procedures, unforeseen conditions may be revealed that necessitate more extensive, costly, or different procedures that originally planned. If FloridaWild’s staff is unable to reach me, I hereby consent to and authorize the performance of such procedures as are necessary and desirable in the professional judgment of the attending veterinarian, provided that the cost of additional procedures will not increase the total fee by more than 25% of that provided in the estimate. We appreciate your trust and will take excellent care of your pet.

I understand that FloridaWild Veterinary Hospital is not staffed 24 hours.

I would like to transport my pet to an overnight facility for after-hours care if overnight hospitalization is required.

I would NOT like to transport my pet to an overnight facility for after-hours care if overnight hospitalization is required.

I have read and fully understand the terms and conditions set forth above.

I understand that checking this box and submitting this form is the equivalent of signing this document in person.

EXOTIC MAMMAL ANESTHESIA AND SURGERY CONSENT FORM

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