Drop Off/Dental/Surgery/Anesthesia Consent Form

Drop Off/Dental/Surgery/Anesthesia

GENERAL CONSENT FORM
Pet's Name
Customer's Name
PLEASE READ

Your pet has been scheduled for a procedure requiring sedation or anesthesia. By signing this form you authorize Sunset Animal Hospital and its agents to administer tranquilizers, anesthetics and/or analgesics that are deemed appropriate for your pet. Please be aware that all drugs have the potential for adverse side effects in any particular animal. The chances of such occurrence are extremely low.

I am aware that the staff is not on premises after hours, and I agree to indemnify Sunset Animal Hospital and its agents harmless from and against any and all legal liability arising from the care that is provided.

In an effort to ensure your pet's safety and to anticipate any problems before they may occur, we have available pre-anesthetic electrocardiogram and blood testing capabilities to detect hidden heart, liver, kidney or other problems, that may increase the risk to your pet. This testing is available for an additional charge. If abnormalities are detected we will attempt to notify you, and the anesthetic procedure may be delayed or modified. Please verify the procedures being performed and indicate your wishes concerning the option of pre-anesthetic testing. If you have questions please ask us, BEFORE signing and submitting this form.

I assume responsibility for all charges incurred in the care of this animal. I understand that a deposit may be and in any additional charges must be paid in full at the time of discharge for any procedure performed at Sunset Animal Hospital.
Pet Parent Emergency Contact
Contact Person Name

First NameLast Name
Primary Phone Number

Area CodePhone Number
Secondary Phone Number

Area CodePhone Number
Drop Off Reason:*
Drop Off with Sedation for:
For SURGERIES Only:

*Please remember no food or water past midnight the night before.*
Surgical Procedure:
I Grant permission to proceed and Extract any infected teeth

YesNo
Acknowledgment, Authorization and Waiver
Please check off all boxes that apply:*

I authorize Sunset Animal Hospital to perform the treatment or necessary procedure to my pet.I confirm that the doctors explained the procedure thoroughly to me and how it will help me with my pet's current condition.I authorize the use of anesthesia and understands the side effects I can experience from it.I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.I understand that my pet may have the need to be hospitalized after surgery, if so I will be responsible for any extra charges which will be discussed with this office.I understand the existing emergencies may take precedence and a late pickup may be required.I acknowledge that all information I provided in this form is true and accurate.
Pet Parent/Customer Signature*

Clear
Date Signed*

MonthDayYear
Should be Empty:

Drop Off/Dental/Surgery/Anesthesia

Pet Parent Emergency Contact

For SURGERIES Only:

Acknowledgment, Authorization and Waiver