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Anesthesia Consent Form

Name: Cirby Ridge Animal Hospital
Address: 1801 Cirby Way STE 1, Roseville, CA, 95661, US
Telephone: 916-789-0123
Price range: $

If your pet is scheduled for a procedure requiring anesthesia, please fill out our Anesthesia Consent Form in advance. This ensures we have your authorization to proceed and allows us to confirm all relevant health information to keep your pet safe.

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Supporting Your Pet’s Safety During Anesthesia

At Cirby Ridge Animal Hospital, we use modern anesthetic monitoring and individualized pain management plans to ensure your pet’s procedure is as safe and comfortable as possible.

What You Need to Know

This form is required for any anesthetic procedure
Submitting it in advance helps us prepare appropriately
We’ll contact you if any follow-up is needed before the procedure

For urgent questions or to speak with a team member, please call us at (916) 789-0123.

Anesthesia Consent Form

Name *

First

Last

Phone *

Email *

Pet's Name *

At Cirby Ridge Animal Hospital, our greatest concern is the well-being of your pet. Your pet is scheduled for an anesthetic procedure. Before putting your pet under anesthesia, we routinely perform a full physical examination. In order to maximize patient safety, we highly recommend, and sometimes require, a pre-anesthetic blood profile. The surgeon may be alerted to the presence of certain conditions that could complicate the procedure, such as dehydration, anemia, infection, diabetes, and/or kidney or liver disease. These tests are similar to what your own physician would conduct prior to you undergoing anesthesia and help ensure the administration of the most appropriate anesthetic regimen.. *

The Quantitative Blood Count (QBC) and Pre-Anesthetic Profile which includes: CBC (PCV (anemia), white blood cell count (infection) and red blood cell count (anemia/bleeding disorder), platelet count (clotting disorder) and Chemistry Profile (BUN and creatinine (kidney), ALKP and ALT (liver), glucose (sugar), total protein (dehydration), and electrolytes (imbalance).
The owner elects to decline the recommended pre-anesthetic blood tests at this time but requests that we proceed with the procedure.

Other tests are available that are not included in the above choices. The tests selected above give the doctor a suitable overview of healthy patients. For those patients who are sick or in their senior years (above the age of 9), a full senior profile can be performed the day of the procedure with the doctor’s recommendation or at the owner’s request.

Our ability to minimize anesthetic and surgical risks and maximize patient safety is greatly enhanced by the completion of a physical examination and blood work prior to a surgical procedure. If you have any questions or concerns about the scheduled procedure, please do not hesitate to call or email at 916-789-0123 / cirbyridge@gmail.com to discuss any aspect of the upcoming procedure.

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Online Forms

Anesthesia Consent Form

Supporting Your Pet’s Safety During Anesthesia

What You Need to Know

Anesthesia Consent Form

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