Hampden Family Pet Hospital - Surgical Anesthetic Release Form

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SURGICAL ANESTHETIC RELEASE FORM
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* This field is required.
Owner’s Name
Pet's Name
Procedure Being Performed
Doctor
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Email* This field is required.
example@example.com
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* This field is required.
Last time pet has eaten
Please Select
Please Select
Yes, Not Recent
Yes, In the last few days
No
Vomiting
Please Select
Please Select
Yes, Not Recent
Yes, In the last few days
No
Diarrhea
Current medications
Food allergies
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Previous adverse reactions to anesthesia/medications?* This field is required.
Yes
No
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If YES, Please Explain* This field is required.
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TREATMENT FOR ANESTHESIA RELEASE

Thank you for choosing us as your pet’s health care provider. Our intent is to give your pet the best possible care. We appreciate your patronage.
1. I am the owner of or authorized agent for the above pet and have the authority to execute this consent.
2. I hereby authorize Hampden Family Pet Hospital, P.C., it’s associated or designed assistants to perform the above procedures or operations and to administer anesthesia as needed.
3. I understand the nature and purpose of the procedure(s), risks involved, and possible complications that could arise. It has been explained to me and I understand that no guarantee can be made legally or ethically regarding any procedure(s) performed.
4. I understand the act of delivering intravenous sedation and inhalant anesthesia involves risks including, but not limited to adverse reaction (allergic reaction), infection and possible death. I consent to the use of such anesthetics as are considered necessary by the person(s) responsible for these services.
5. Your pet will also have an intravenous catheter placed before the procedure. This requires that a small amount of hair be shaved from your pet’s leg(s).
6. If deemed necessary the undersigned owner or guardian consents to resuscitative efforts (CPR) for the above pet.
*
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It is imperative that we are able to reach you by phone during your pet’s procedure.* This field is required.
Area Code
Phone Number
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I need to be contacted prior to any surgical tooth extractions. * This field is required.
YESNO
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There are occasions when we discover unrelated issues/problems at the time of your pet’s procedure that warrant further attention (Ex: ear infection, lump, broken tooth, etc…). Should an additional condition or problem present itself during the procedure that needs to be addressed, we will make every effort to contact you by phone. However, in the event that we are unable to reach you, we will address the condition in a manner that is in the best interest of your pet based on our medical expertise.
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IF I CAN NOT BE REACHED WITHIN TEN MINUTES BY PHONE

I authorize my veterinarian to move forward with recommended treatments
(*These treatments may add additional costs to your estimate)
I DO NOT authorize my veterinarian to perform any other additional treatment (completion of these treatments at a later date will require an additional anesthetic procedure with associated costs).
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Additional Notes
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I have read and fully understand this consent form. I understand that I should not sign this form if all items, including my questions, have not been explained or answered to my satisfaction, or if I do not understand any of the terms or words contained in this consent form.
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Signature* This field is required.
Clear
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Date* This field is required.
Date
Year
Month
Day
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