Anesthetic Release Form

Date*

Date

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Alternate Phone Number*

Area CodePhone Number

Account Number (if known)

Patient Name*

Patient Date of Birth or Age*

Appointment Date*

Date

Procedure*

Please read and understand the following:

1. I am the owner or appointed liaison of the patient indicated above and I am over the age of 18.

2. I understand that if the above named pet is found to have fleas a flea medication will be given at an additional cost to me.

3. I understand that in order for a procedure requiring anesthesia or sedation to be performed safely my pet will be shave and an intravenous catheter will be placed in my pet using aseptic technique. This is to ensure reliable venous access for the purposes of pain management, sedation, antibiotic therapy, fluid support and possible emergency intervention.

4. I accept that an initial medical treatment plan will be reviewed with me by a veterinary technician where the medical and financial aspects of this anticipated treatment plan will be agreed upon prior to admission of my pet into the hospital for the above indicated procedure.

5. I agree to pay in full for services rendered while my pet is hospitalized prior to him/her being discharged. This includes any fees related to services deemed necessary for my pet in the occurrence of a medical/surgical emergency or change in medical therapy due to unforeseen circumstances.

6. If an emergency situation may occur and I am unreachable immediately at either of the above listed contact phone numbers I authorize the attending veterinarian to proceed with medical care under their judgment.

7. I acknowledge that no guarantees can be made regarding medical diagnosis, intervention, therapy and recovery plans pertaining to my pet except that all reasonable precautions against injury, escape, illness, and death will be taken while hospitalized.

8. I understand that there are risks associated with any procedure that requires anesthesia or sedation and I have spoken to the veterinarian regarding my concerns related to those risks that include, but are not limited to escape, injury, illness and death. I accept the risks associated with my decision to have the above indicated procedure performed on my pet. I do not hold Sacajawea Healthcare for Pets, its doctors, staff or associated entities responsible for any unforseen outcome related the procedure being performed on my pet today.

Signature*

CPR DIRECTIVE

In the event of an unforeseen medical emergency that may require life saving measures to be taken while my pet is in the care of Sacajawea Healthcare for Pets, I direct the following emergency option:*

Full CPR measures (Cardio Pulmonary Resuscitation: I understand there are fees associated with initiating such medical intervention that can quickly contribute and estimated additional cost of $700-$900 to my pet's medical invoice of services. I will be responsible for these fees regardless of the outcome of life sustaining measures.DO NOT RESUSCITATE: I understand there will be no extensive intervention measures in the event of a cardiopulmonary arrest.

I understand that my pet is to be picked up after the procedure is finished at the direction of the medical staff of Sacajawea Healthcare for Pets. I understand that not picking up my pet will result in additional charges for overnight hospitalization.

I have fully read, understand and agree to the above statements of this consent.*

Signature

Date*

Date

When did your pet last eat?*

Has water been available to your pet within the last 8 hours?*

YesNo

Please list any medications (including flea prevention) or supplements your pet is currently taking and the last time they were given.*

Does your pet have any food or environmental allergies you are aware of?*

YesNo

Has your pet recently had any of the following?*

If yes, please list occurrences and the duration.*

Has your pet traveled outside of the Puget Sound area within the last 6 months?*

YesNo

If yes, please list where, when and the duration of time.*

Has your pet been to any other veterinarian in the last 6 months?*

YesNo

Name and phone number of other veterinarian(s). *