Anesthesia Consent Form for Fluoroscopy
CFL
Has the pet fasted? (No food for 6 to 8 hours)
*
Please Select
Pull down to select answer
Yes
No
Referring Veterinarian
*
Referring Clinic Name
*
Your first name
*
Your last name
*
Pet's name
*
Species/Breed
*
Sex
*
Pull down to select answer
Male
Female
Neutered / Spayed?
*
Pull down to select answer
Yes
No
Pet's age
*
I am the owner or agent of the above-mentioned pet, and hereby understand, consent, and authorize the following procedure(s):
Please check the left hand box on each item below to indicate your consent for each.
*
By clicking on the submit button, I certify that I have read and consented to all of the items above.
Image Consent
Signature
*
Submit
Should be Empty: