Animal Care Clinic - Anesthesia and/or Procedure Authorization

1

Owner Information

Owner Name

Phone

Email

2

Patient Information

Pet's Name

Sex

Species

Breed

Color

Age

Weight

3

I undersigned am responsible for the above pet and have the authority to grant my consent to the hospitalization and treatment and/or operation upon my pet. I understand the surgery or treatment contempaled is

4

Procedure

Bloodwork

Xrayy

Vaccines

5

Pre-Op blood work is highly recommended by the veterinarian for any procedure involving anesthesia.

I authorize Pre-Op bloods prior to sedation/anesthesia.

I do not authorize Pre-Op bloods.

6

I understand that my pet may be sedated and/or anesthetized. Althrough every effort is made to make this procedure as safe as possible for my pet, there are inherent risks with anesthesia and surgery that may include the possibility of death. I am encouraged to discuss any concerns I have about those risks with the veterinarian. I will not hold the veterinarian, Clinic, Hospital or staff responsible in any manner and assume all risks.

7

In the situation of an adverse event while your pet is hospitalized, every effort will be made to follow your wishes. In all cases we will make every attempt to contact you as soon as possible.

8

Please initial your preference:
blanks Basic CPR
blank DO NOT RESUSCITATE.

All charges including boarding costs shall be paid upon release from the hospital.

9

After carefully reading the above. I have signed the agreement.* This field is required.

Clear

10

Print Name

11

Date