Salmon River Mobile Veterinary Clinic Sedation / Anesthesia Authorization Form

Salmon River Mobile Veterinary Clinic Sedation / Anesthesia Authorization Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number you can be reached at today.*
Please enter a valid phone number.
Alternate phone number or message number*
Please enter a valid phone number.
Email*
example@example.com
Pets Name*
Species*

DogCatRabbitPocket Pet
If a pocket pet, please specify.
Breed*
Age*
Does your pet have any known allergies?*

YesNo
If your pet has allergies please specify.
Is your pet on any medications or supplements?*

YesNo
If your pet is on medications or supplements, please list.
What procedure are you authorizing? *
I understand it is suggested by Salmon River Mobile Veterinary Clinic to have pre anesthesia bloodwork completed before any procedure involving anesthesia.*

I want the pre anesthesia bloodwork completedI understand that by declining the pre anesthesia blood panel, my pet could have negative complications, including death. I decline the suggested bloodwork.
Authorization

Please read, confirm, initial and date below.
I certify I am 18 years old or older and the owner or authorized agent of the owner, for the above named animal.

I understand that every reasonable precaution is taken to ensure the safety of my pet. I have been advised on the nature of the treatment that will be performed and I understand the outcome cannot be guaranteed.

I understand that chemical sedation/anesthesia and surgery always carry some element of risk and that by signing this, I share in assuming those risks.

My veterinarian has talked with me regarding these risks and my questions have been answered to my satisfaction.

I understand that Salmon River Mobile Veterinary Clinic and its staff cannot always reasonably predict complications. I understand that complications can include unexpected death, and this can happen at any time, including before, during or after a procedure that includes the utilization of anesthetics.

I understand that every reasonable safety measure will be taken to assure the most positive outcome possible.

I understand that payment is due at the time the services are rendered.
Should unexpected life-saving emergency care be required and the staff cannot reach me, the staff has my permission to provide such treatment and I agree to pay for such services.*

CPRDo Not Resuscitate
I understand that my signature on this form indicates that I have had my questions answered regarding this procedure and its risks and that I reasonably understand the risks associated with these procedures.

I hereby consent and authorize Salmon River Mobile Veterinary Clinic and its staff to sedate/anesthetize my pet and perform the procedures and/or surgery discussed with me.
Date*

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Date
Signature

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