SOUTHWEST VETERINARY HOSPITAL ANESTHESIA CONSENT

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					                                PROFESSIONAL AND PERSONAL SERVICE FOR YOU AND YOUR PETS
GARY R. SARGENT, DVM                                                                        960 WEST MOANA LANE, SUITE 102
ERIN L. RASMUSSON, DVM                                                                                RENO, NEVADA 89509
WWW.SWVHRENO.COM                                                                                         (775) 825-SWVH

                SOUTHWEST VETERINARY HOSPITAL ANESTHESIA CONSENT

         The goal of Southwest Veterinary Hospital (SWVH) is to provide a standard of excellence in
              patient care in a modern, fully equipped, small animal hospital. A hospital that is
           comfortable for our patients, attractive to our clients and a pleasant workplace for the
         doctors and support staff. Thank you so much for choosing SWVH. We understand that you
           have many options when it comes to the care and treatment of your dogs and cats. We
                          appreciate the opportunity to show you what we do best.

        INHERENT RISK: There are inherent risks involved with any type of anesthetic, surgical or invasive
        procedure including, but not limited to, anesthetic complications, surgical wound infections, surgical
        procedural failure, and even the untimely or unanticipated death of a patient. The SWVH staff are
        committed to achieving 100% success in every anesthetic or surgical procedure performed; however, no
        outcome can be guaranteed 100%.

                                                                                                  Initials _______

        PROCEDURAL FEES: Surgical/procedural fees are an estimate only. Unanticipated events occasionally
        occur, which may require additional anesthetic time, additional surgical materials, prolonged or intensive
        postoperative care, etc. Your doctor will keep you apprised of any changes in the estimated fee for your
        pet’s procedure. Please understand that follow-up radiographs, bandage or splint changes, surgical
        implant removal, and professional fees (if indicated) for future visits are charged at our regular and
        customary fees beyond estimated surgical/procedural fees. All fees are due at the time of discharge.

                                                                                                  Initials _______

        ANESTHETIC CODE: All patients are continually monitored throughout anesthesia procedures. Very
        rarely a patient may arrest (causing heart beats and/or respirations to cease) during an anesthetic
        procedure or because of a serious medical condition. SWVH staff needs to know whether you want
        closed C.P.R. (cardio-pulmonary resuscitation) performed on your dog or cat and be responsible for the
        costs incured. The doctor can explain what typically happens during a code.

        Yes, perform C.P.R. _______                                         No, do NOT perform C.P.R. _______

        I do hereby consent to surgery and treatment by Southwest Veterinary Hospital as may be
        necessary for my pet’s injury or condition. I have been informed of the attendant risks and
        options of surgery, procedure or treatment and understand the services as stated.

        Signature: _________________________________             Patient: _______________ Date: __________

        Procedure: ____________________________________________ Estimate: ______________________

        Contact phone numbers: (H) ___________________ (W) _________________ (C) _________________