718 El Camino Real, San Carlos, CA 94070

Anesthesia, Dental & Surgery Consent Form

Owner's Name

Phone

Pet's Name

Species

Cat Dog Other

Breed

Date of Procedure

Procedure Name

Explanation of Risks

Last Meal / Time

Last Treatment / Time

Emergency / CPR Preference

CPR (Full resuscitation) DNR (Do not resuscitate)

I acknowledge the estimated cost of the procedure, and I understand that the final cost may vary if additional treatment is required.

I authorize Revive Veterinary Care to administer anesthesia and to perform the procedure described above, including any additional procedures deemed necessary in the professional judgment of the attending veterinarian.

I understand that anesthesia, dental and surgical procedures carry inherent risks, including the risk of complications or death, and that no guarantee has been made as to the result of the procedure.

Owner / Authorized Agent Name (printed)

Date

Owner Signature