Anesthesia Consent Form

Name: Veterinary Healthcare Center
Address: 241 W Pomona Blvd, Monterey Park, CA, 91754, US
Telephone: (323) 890-9000

Client's First Name *

Client's Last Name *

Date

Pet's Name *

Age *

Sex *

Male

Female

Procedure(s) *

Date of pet's last meal *

Time of pet's last meal *

Has your pet had aspirin or any other medicine within the past 48 hours? *

Yes

Which medication(s)?

What dose & strength?

When?

How many tablets, capsules, or ccs were administered? *

Emergency Contact Information

In case of an emergency I can be reached at:

Home Phone Number

Work Phone Number

Other

I have read and agree to the disclaimer *

I Agree

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New Patients Welcome

Veterinary Healthcare Center is accepting new patients! Our experienced vets are passionate about the health of Monterey Park companion animals. Get in touch today to book your pet's first appointment.

(323) 890-9000 Contact

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Anesthesia Consent Form

Emergency Contact Information

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