You can always press Enter⏎ to continue
Hampden Family Pet Hospital - Surgical Anesthetic Release Form
  • 1

     

    SURGICAL ANESTHETIC RELEASE FORM

     

    Press
    Enter
  • 2
    Press
    Enter
  • 3
    Press
    Enter
  • 4
    • Yes, Not Recent
    • Yes, In the last few days
    • No
    • Yes, Not Recent
    • Yes, In the last few days
    • No
    Press
    Enter
  • 5
    Press
    Enter
  • 6
    Press
    Enter
  • 7

         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.

    ANESTHETIC RELEASE:

    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.

    Press
    Enter
  • 8
    • Yes
    • No
    Press
    Enter
  • 9
    Press
    Enter
  • 10

    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.

    Press
    Enter
  • 11

    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).

    Press
    Enter
  • 12
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 13

    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.

    Press
    Enter
  • 14
    Clear
    Press
    Enter
  • 15
    Pick a Date
    Press
    Enter
  • Should be Empty:
Question Label
1 of 15See AllGo Back
close