Anesthetic statement

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For the administration of anesthesia, we would like to ask you to complete the form on this page as fully as possible and sign it digitally.

Anesthesia Statement

Owner / Representative Details

Salutation

First name

Last name

Horse name

Breed

Chip number

Admission date

You have presented your horse to us for a CT scan or surgery.

For this procedure, your horse must be placed under general anesthesia. This always entails risks, even for a horse in good condition. We will do everything possible to minimize this risk, but unfortunately, a small risk always remains.

On a large scale, the risk of death during anesthesia in horses is about 1% of cases. This risk is greater when it concerns:

Emergency operations
Heavy horses
Old horses
Foals
Friesians
Horses with pre-existing heart or lung problems

Examples of possible complications include heart failure, myositis, thrombophlebitis, difficulty standing up (fractures), neurological problems, digestive problems, laryngeal edema (airway problems), etc.

Prior to anesthesia, we will perform a pre-anesthetic examination on your horse. Should any abnormalities arise during this, you will be informed. Anesthesia is administered using state-of-the-art techniques, and your horse will be closely monitored during and after anesthesia.

It is possible to cover the anesthesia risk by taking out special insurance. The owner is responsible for taking care of this themselves.

Furthermore, we would like to ask you to complete the questionnaire below as fully as possible. If you have any questions after completing it, you can ask one of the veterinarians.

Has the horse been vaccinated against influenza/tetanus during the past year?

Has the horse had colic in the past?

Is the horse sensitive to colic?

Has the horse been sick the last 6 months?

Did the horse have surgery in the last 3 months?

If yes, which kind of surgery?

To your knowledge, is the horse suffering from a chronic sickness or disease?

If yes, which?

Is the fitness of the horse reduced?

Has your horse travelled a lot in the past few days?

Has the horse been given medication during the past 2 weeks?

If yes, which?

Is the horse oversensitive to specific medicines?

If yes, which?

Did anything noteworthy occur during previous sedations or anaesthesia?

If yes, which?

If the horse is not excluded from slaught, can Via Nova Equine Services BV do this for you?*

**For the treatment of your horse, in some cases we are obliged to administer medicines that are not specifically permitted for horses or other food-producing animals (cascade regulation). If you do not wish to exclude your horse, we will not be able to use many medicines. The medicines used must be recorded by us in the passport. Costs will be charged for this extra administrative procedure.

In your opinion, are there additional factors that could be of importance?

If yes, which?

General

The undersigned (name of owner/owner's representative) declares to have taken note of the risks of general anesthesia and hereby gives consent for the general anesthesia of his/her horse as mentioned in this form.

Agree

Date of signing

General term

I have read the General Terms and Conditions and Addendum and agree to them.

Please remind us that the bill must be paid at the reception immediately after the consultation and/or treatment. This can be done by Bancontact/debit card (preferred), credit card (VISA/Mastercard), or cash. Please contact us if you are not present yourself and would like to pay via a payment link when your horse goes home (= instant payment).

If you are human, leave this field blank.