Anesthesia/Sedation Consent Form "*" indicates required fields Patient InformationID Number*First Name*Last Name*Age*Sex*Breed*Species*Pet InformationWhat time did your pet last eat?*Is your pet exhibiting the following symptoms? Initial all that apply:* Vomiting Diarrhea Lethargy Coughing Sneezing I hereby authorize the following procedure(s) Initial all that apply:* Neuter/Spay Dental Mass Removal Sedation Other OtherFor dental procedures, please review the following options and initial which option you prefer:* I give the attending veterinarian permission to do any extractions and/or procedures deemed necessary while my pet is under anesthesia Please contact me regarding any extractions and/or other procedures. If I am unavailable, I authorize you to proceed with any necessary extractions and/or additional procedures If I am unable to be contacted by phone, I do not authorize any extractions and/or additional procedures to be performed. I understand my pet may need to come back at a later date for a second anesthetic procedure. We offer a pre-anesthetic blood profile to minimize anesthetic risk This blood test checks multiple organ functions, particularly the kidney and liver. These two organs are responsible for processing the anesthetic gas during the procedure. In addition, it will assess RBC, WBC, platelet count, and glucose levels This test is strongly recommended for all pets, especially those over six years of age, as well as pets with pre-existing conditions Please initial your choice below:* I approve the pre-anesthetic blood profile Pre-anesthetic blood work has already been performed on my pet I have been informed of the pre-anesthetic blood profile and choose NOT to do this test Please read and initial the following:* Pet must be free of fleas and ticks. If fleas and/or ticks are found upon admission, treatment/prevention will be administered at an additional charge I have received the procedure estimate, understand it, and have had all of my questions answered to my satisfaction For dental procedures: I hereby consent my pet to be photographed and authorize the use or disclosure of such photograph(s) for social media and/or advertising purposes CPR: In the event that your pet should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of your pet's status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion.Please initial your choice below:* I agree to CPR being performed in case of arrest I elect a “DO NOT Resuscitate” status in case of arrest I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age. I have been informed that there are certain risks and complications associated with sedation, anesthesia, and/or any operation/procedure and that the risks/complications have been explained to me. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated. I authorize the use of appropriate anesthesia and pain relief medication as needed before, during or after the procedure. I have been informed that there are risks associated with the use of any medication. The nature of these operations or procedures has been explained to me and I understand what will be done. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care and my questions have been answered to my satisfaction. I accept that my financial obligations remain regardless of the outcome. I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment. Signature*
