Anesthesia/Sedation Consent Form

Your Name*

First NameLast Name

Pet's Name*

Email*

example@example.com

Date of scheduled surgery/sedation:*

Date

It is imperative that we be able to reach you in a timely manner while your pet is here at Hilltop Animal Hospital.

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

Area CodePhone Number

YesNo

Alternative Contact Name*

First NameLast Name

Alternative Contact Phone*

Area CodePhone Number

Relationship to your alternative contact? *

Reason for your pet's anesthesia / surgical admission?*

Please list surgery type (i.e. Spay, Neuter, Dental Cleaning, Mass Removal etc.)

YesNoUnsure

If yes, please describe/provide more information

YesNoUnsure

If yes, please describe/provide more information

Please list any current medications, supplements, topical treatments your pet is receiving and when they were last given:*

YesNoI Am Not Sure

YesNo

Does Your Pet Have Known Health Concerns and/or Chronic Disease or Conditions?*

If yes, please tell us more. If no, please note N/A

Is there anything else you would like to discuss today?*

If yes, please tell us more. If no, please note N/A

Are there pictures or video that would help us with your pet's scheduled procedure?

Browse Files

Please upload if available.

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 Hilltop Animal Hospital. 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 understand that my pet cannot have any food after 9pm the evening prior to surgery/sedation. (water is ok) If my patient eats the morning of surgery I understand that the surgery/sedation may have to be rescheduled.*

Initial

Nocita Authorization

Nocita (bupivacaine liposome injectable suspension) is a long-acting local anesthetic that provides up to 72 hours of postoperative pain relief.

Nocita is made of bupivacaine local anesthesia that is encapsulated into mulivesicular liposomes and released over time.

The pain control provided by Nocita is significant and can lead to a marked improvement in post surgical comfort and recovery. Nocita is labeled for single-dose infiltration into the surigcal site to provide local postoperative analgesia in dogs.

Because of the importance of pain control, Nocita may be used in other types of surgeries when it is deemed safe to do so. In these cases the use will be off label. Your signature below indicates your consent for Hilltop Animal Hospital to use Nocita at the time of surgery to augment your pet's post-operative pain control and you understand that in select instances it may be used off label when deemed necessary by the surgeron.

This pertains to Extensive Soft Tissue Procedures and Orthopedics only: Nocita Authorization- Nocita (bupivacaine liposome injectable suspension) is a long-acting local anesthetic that provides up to 72 hours of postoperative pain relief. Nocita is made of bupivacaine local anesthesia that is encapsulated into mulivesicular liposomes and released over time. The pain control provided by Nocita is significant and can lead to a marked improvement in post surgical comfort and recovery. Nocita is labeled for single-dose infiltration into the surgical site to provide local postoperative analgesia in dogs. Because of the importance of pain control, Nocita may be used in other types of surgeries when it is deemed safe to do so. In these cases the use will be off label. Your signature below indicates your consent for Hilltop Animal Hospital to use Nocita at the time of surgery to augment your pet's post-operative pain control and you understand that in select instances it may be used off label when deemed necessary by the surgeon. *

Initial

DENTAL PROPHY PATIENTS ONLY: In the event that extractions/oral surgery is necessary we will contact you with an estimate for the additional cost. If you are unavailable you will have 5 minutes to return our call, otherwise your pet will be woken up from anesthesia and a second surgery will need to be performed. (if your pet is not having a dental please put n/a)*

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.

I acknowledge my choice regarding resuscitation choice for my pet as noted above.*

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.*

Initial

After-Hours Care Acknowledgement

Your pet’s well-being is our highest priority. While our hospital is not staffed 24 hours a day, we will provide attentive care and monitoring during their stay with us. If at any point we determine that your pet would benefit from continuous overnight supervision or more advanced support, we may recommend transfer to a trusted 24-hour emergency facility. By signing below, you acknowledge that you understand this policy and the possibility of transfer to ensure the best care for your pet.

Please allow 5-10 minutes for the check in process to be completed. Our staff will review the care plan for your patients visit, associated costs and answer any questions you may have. Thank you!

Anesthesia/Sedation Consent Form

Authorizations