Skip to content
Keyboard Accessible Menu
330 Main Ave.,
Norwalk, CT 06851
24/7
Guardian Vet
Give us a call!
(203) 847-7757
Request an Appointment
About
Veterinarians
Staff
Veterinary Employment
Services
Preventative Medicine and Wellness Care
Puppy and Kitten Care
Senior Pet Care
Diagnostics
General Medicine
Dental Care
Veterinary Surgery
Anesthesia
In-House Pharmacy
Nutrition and Diet
Microchipping
Pet Boarding
Client Center
Educational Links
FAQs
Online Pet Portal
Pet Health Articles
Pet Health Insurance
Promotions
Online Store
Contact
Emergency
About
Veterinarians
Staff
Veterinary Employment
Services
Preventative Medicine and Wellness Care
Puppy and Kitten Care
Senior Pet Care
Diagnostics
General Medicine
Dental Care
Veterinary Surgery
Anesthesia
In-House Pharmacy
Nutrition and Diet
Microchipping
Pet Boarding
Client Center
Educational Links
FAQs
Online Pet Portal
Pet Health Articles
Pet Health Insurance
Promotions
Online Store
Contact
Emergency
Consent Form for Tranquilizers, Surgery, and Dental Procedures
Company
This field is for validation purposes and should be left unchanged.
Owner's Name
(Required)
First
Last
Owner's Email
(Required)
Pet's Name
(Required)
Procedure
(Required)
Contact Phone #1
(Required)
Contact Phone #2
Please be aware that these contact numbers are used to contact you during procedures if necessary. Please give a number that you will be available to answer.
I am the owner or designated representative of the above mentioned pet. I consent to the above listed procedure(s) and authorize Norwalk Animal Hospital to administer anesthetics and/or tranquilizers, including appropriate medications to my pet. I understand there are potential risks when using anesthetics and/or performing surgery and that no results are guaranteed. In the event of an adverse reaction, I authorize the doctor to do what is in the best interest of my pet.
(Required)
I consent
Signature
Date
MM slash DD slash YYYY
Pre-operative instructions: Please do not feed your pet after 12am midnight the evening before a scheduled procedure. There is no restriction on drinking water. Plan to arrive at the hospital between 8-9am and allow 30 minutes for check-in procedures.
Surgeries and Dentals typically take place between 11am and 3pm. You will receive a call from a doctor or technician when your pet is in recovery. If your pet is to go home on the same day, they will be discharged between 4:30pm and 6pm. If they need to stay overnight they would go home at 10am the following morning.
Please complete this section if your pet is receiving a TRANQUILIZER:
Check all that apply:
Patient has a history of seizures.
Patient has a history of adverse drug reactions.
Patient has not been eating and drinking normally
Patient has other signs of illness.
If you checked any of the above, please explain:
(Required)
I understand that Norwalk Animal Hospital has the right to refuse service to any animal for whom tranquilization or anesthesia is deemed a health risk.
Please complete this section if your pet is here for ANESTHESIA (SURGERY and DENTAL patients):
We routinely run pre anesthetic bloodwork to check your pets health prior to anesthesia, the following would be in addition to that bloodwork and additional charges would apply. Please check any additional testing below you would like us to do.
Add an electrocardiogram to my pet’s pre-anesthetic work-up?
Microchip my pet to aid in pet identification?
Add ultrasound (screening)
Add chest radiograph (lateral view)
Please list all medications (current and recent) and whether they were given today, or will be given later today. (If no medications are needed, please type none).
(Required)
Please complete this section if your pet is here for a DENTAL procedure only:
Evaluations under anesthesia may reveal hidden dental disease that could not be identified in your pet’s exam. Please indicate below how you would like the doctor to proceed with any treatments:
Do no further work beyond the basic cleaning and polishing.
Do only those procedures that will arrest infection or pain on a short term basis. This may include the extraction of one or more teeth. Future work may be needed*
Do any and all procedures that will promote good oral health now and in the future*
Call before any additional work is completed** IF THIS BOX IS CHECKED, PLEASE SELECT A SECOND OPTION ABOVE IN CASE WE CANNOT REACH YOU BY THE PHONE NUMBER YOU PROVIDED
*additional charges will apply for any procedures beyond basic cleaning and polishing. ** additional anesthesia time and charges are required for phone consultation delays.
Please complete if your pet is here for a SPAY or NEUTER only:
We recommend removing deciduous teeth that have not yet fallen out as they can cause the emerging adult teeth to be pushed out of alignment, causing bite issues.
I give permission to remove any remaining deciduous teeth.
I do not wish to have deciduous teeth removed at this time. I understand that my pet may need an additional anesthetic procedure to remove them in the future.
Add upgraded bloodwork (advanced chemistry)?
Yes
No
I understand that an estimate of fees for the above services will be provided to me upon my request and may vary significantly depending on the need for additional services. I am encouraged to discuss all fees before services are rendered. If additional work is needed and agreed to during a phone consultation I will be responsible for payment.
(Required)
I agree
I certify that I am 18 years of age or over and agree to assume financial responsibility for the service fees. Payment is due in full at the time my pet is discharged.
(Required)
I agree
Owner Name
(Required)
First
Last
Owner Signature
(Required)
Date Submitted
(Required)
MM slash DD slash YYYY
CAPTCHA
Client Center
Thank you for making us one of the best!
Facebook-f
Instagram
Youtube
New Client Form
Financial Policy/Social Media Consent Form
Consent Form
Boarding Form
Weekend Boarding Pickup Form
