Drop Off Consent Form

Drop Off/Sedation/Anesthesia Consent Form

Please fill out this form in entirety to ensure we can provide your pet with the best possible care.
Pet's name *

First Name Last Name
Your name *

First Name Last Name
Where can we call you at while your pet is here? *

Area Code Phone Number
Is there anyone else we can call regarding your pet while they are here today? *

Yes No
Alternative contact name *

First Name Last Name
Alternative contact phone *

Area Code Phone Number
Reason for your pet's visit today?
If surgical, please list surgery type (i.e. Spay, Neuter, Dental Cleaning, Mass Removal etc.)
Please note: a treatment will be applied at the owner's expense to any pet with evidence of fleas, flea dirt, or ticks.
Has your pet had any food since midnight the night before drop-off? *

Yes No Unsure
What food is your pet currently eating? *
Please list brand, type, and amount given daily.
Has your pet been coughing, wheezing, or breathing hard? *

Yes No Unsure
Has your pet been vomiting or having diarrhea? *

Yes No Unsure
Does your pet have any allergies? *

Yes No Unsure
If yes, please list:
Is your pet taking any medications? *

Yes No
Please list all current medications and dosage instructions for your pet below:
NOTICE: If your pet is diabetic, please call our office at (360) 779-4166 for pre-sedation feeding and dosing instructions.
Are there pictures or video that would help us with our exam today?

Browse Files
Please upload if available. Cancel of
Is there anything you would like the doctor to know regarding today's visit?
Authorizations
I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Poulsbo Marina Veterinary Clinic. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian. *
Initial
I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges. *
Initial
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital). *
Initial
In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference: *

Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred (starting range of $150-300). Please do not proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred.
*

Please sign here Clear
Should be Empty:

Drop Off/Sedation/Anesthesia Consent Form

Authorizations