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Informed Consent · Recommended

Secure Informed Consent Before Every Pet Surgery

Help pet owners make informed surgery and anesthesia choices with a consent form covering health screening, bloodwork, IV fluids, and resuscitation wishes.

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formbuilder.ai/f/veterinary-surgical-procedure-anesthesia-informed-consent-form

Veterinary Surgical Procedure & Anesthesia Informed Consent Form

Owner / Authorized Agent Name

· · ·

Phone Number (Reachable on Proce

· · ·

Email Address

· · ·

Submit

This Veterinary Surgical Procedure & Anesthesia Informed Consent Form gives your clinic a clear, organized way to document owner approval before any surgery or procedure that requires anesthesia. It begins by collecting owner or authorized agent details, a phone number where they can be reached on procedure day, and key information about the patient, including name, species, breed, sex and reproductive status, and age. A pre-anesthetic health screening section then confirms whether fasting instructions were followed, asks about signs of illness in the past seven days such as vomiting, diarrhea, coughing, or lethargy, and records current medications, supplements, allergies, and past anesthesia reactions.

Designed for veterinary hospitals, general practices, spay and neuter clinics, mobile surgical services, and specialty or emergency practices, the form also walks owners through important anesthesia decisions. Owners can approve or decline pre-anesthetic bloodwork and IV catheter placement with fluid therapy. Each option includes a plain-language explanation of why it matters. Owners can also indicate their resuscitation preference if cardiac or respiratory arrest occurs.

Replacing paper consent sheets with an online form shortens check-in, prevents missing or illegible answers, and gives your team a complete, organized record before the patient is admitted. Owners can complete it on any device before drop-off, while your veterinarians receive the details they need to build a safe, individualized anesthesia and surgical plan. Customize the fields to match your protocols, add your clinic's policies, and start collecting consent today.

3 Pages

20 Questions

~7min To complete

Free No credit card needed

Field types Single Choice ×3 Short Text ×2 Dropdown ×2 Long Text ×2 Date ×2 Yes / No ×2 Full Name Phone Email number Multiple Choice termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Owner & Pet Information 8 questions

Owner & Pet Information

Thank you for trusting us with your pet's care. Please provide accurate contact details and information about your pet below. This helps our veterinary team prepare a safe, individualized anesthesia and surgical plan. It also ensures we can reach you promptly on the day of the procedure.

1 Owner / Authorized Agent Name * Full Name

2 Phone Number (Reachable on Procedure Day) * Phone

3 Email Address * Email

4 Pet's Name * Short Text

5 Species * Dropdown

6 Breed * Short Text

7 Sex / Reproductive Status * Dropdown

8 Pet's Age (Years) * number

Page 2 Procedure & Pre-Anesthetic Health Screening 5 questions

Procedure & Pre-Anesthetic Health Screening

1 Procedure(s) to Be Performed (as discussed with your veterinarian) * Long Text

2 Scheduled Procedure Date * Date

3 Has your pet followed the pre-surgical fasting instructions provided by our clinic? * Yes / No

4 Has your pet shown any signs of illness in the past 7 days (vomiting, diarrhea, coughing, lethargy, or decreased appetite)? * Yes / No

5 Current Medications, Supplements, Allergies & Past Anesthesia Reactions (note any doses given today) Long Text

Page 3 Anesthesia Options & Consent 7 questions

Anesthesia Options & Consent

1 Pre-Anesthetic Bloodwork (screens organ function and detects hidden health issues before anesthesia) * Single Choice

2 IV Catheter & Fluid Therapy (supports blood pressure and hydration and provides emergency drug access) * Single Choice

3 Resuscitation Preference (if cardiac or respiratory arrest occurs) * Single Choice

4 Optional Add-On Services (additional fees apply) Multiple Choice

5 I certify that I am the owner or authorized agent of the pet named above and am at least 18 years of age. I authorize the veterinary team to administer sedation and/or general anesthesia and to perform the procedure(s) listed. I also authorize any emergency treatment needed to protect my pet's life if I cannot be reached. I understand that anesthesia and surgery carry inherent risks, including adverse drug reactions, bleeding, infection and, in rare cases, death. I understand that no guarantee of outcome has been made. I have reviewed the treatment estimate provided and accept financial responsibility for all charges incurred, payable in full at discharge. * termsandconditions

6 Owner / Authorized Agent Signature * Signature

7 Date Signed * Date

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.