C-Section Release and Sedation Consent Form

C-Section Release and Sedation Consent Form
You have decided to proceed with a Cesarean Section for your puppy’s delivery. There is some information we would like to know prior to proceeding with the surgery to help ensure a successful outcome for you and your babies.By signing this form, I understand that proceeding with a cesarean section of my dog without her being in active labor may result in premature puppies. I understand that these puppies can die from no fault of the veterinarian or the process as premature puppies may not be fully developed. I also understand that placing the mother under anesthesia during pregnancy and while not likely, there is a risk of an anesthesia reaction which in rare cases could end in death to both the mother and the puppies.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Pet's Name*
Breed*
Color
Age/Date of Birth*
Last Breeding Date*

MonthDayYear
Date
Date of Gestation (0-70)
YesNoWould like to discuss it further with a member of your medical staff
**I have been provided with estimated fees for the procedure and/or treatments for which the animal is being admitted to the clinic. The cost of a c-section varies by the needs and weight of each pet, along with whether it is performed during or after business hours. It can range from $700-$1200. I understand that I assume financial responsibility for all services rendered and that all payment is due at the time I collect my pet.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty: