ANESTHESIA AND SURGERY/SEDATION FORM

Pet Name:*

Owner Name:*

ARCHIVE -Contact Number(s) for procedure day:

Note: It is important that we be able to reach you. Please have your phone on and available.

Contact Number for procedure day:*

Note: It is important that we will be able to reach you. Please have your phone on and available. Format: (000) 000-0000.

Alternate Contact Number for procedure day:

Note: It is important that we will be able to reach you. Please have your phone on and available. Format: (000) 000-0000.

Requested Procedure(s):*

**Please note that the person listed above will be expected to make medical decisions for your pet, particularly in dentistry where disease cannot be fully assessed until the procedure. All family members should be comfortable that the person listed will make these decisions on behalf of your pet and family**

My pet last ate at:*

Medication your pet typically takes (and last times):*

Note: Please be sure to give us the last times of medication administration when you drop off

What date did your pet last receive flea prevention and what was the name of the product?*

Do you have any additional requests or questions for procedure day?

Note: Please be sure to give us the last times of medication administration when you drop off

(ARCHIVE) Do you have any additional requests or questions for procedure day?

RECOMMENDED ITEMS TO CONSIDER (select Yes or No)

ANTI-NAUSEA SUPPORT [$57 for pets under 65lb, $73 for pets over 65lb] - Nausea can be one of the most unpleasant parts of anesthesia for pets and people. This treatment will help your pet feel better, guard against vomiting while your pet is under anesthesia, and get them back to eating and acting normally as quickly as possible. We feel strongly that this treatment is a great benefit to many patients, and the cost is the only reason it is not automatically included with our sedated procedures.*

YesNo

DENTAL RADIOGRAPHS (Dental Procedures Only) [$120]: A surprising number of dental problems (tooth root abscesses, root resorption, tooth root fracture, periodontal disease) can go hidden under the gumline and unidentified even after careful surface examination. Routine full mouth dental radiographs allow us to make the best treatment decisions for each tooth. Do you want us to perform full-mouth dental radiographs on your pet?

YesNoMy pet is not having a dental procedure

ACKNOWLEDGMENTS: (Please read and initial each statement, then sign below)

I understand that Central Providence Veterinary Hospital does not extend credit and agree to pay this account in full at the time services are rendered. *

Please initial

I am aware that there are potential risks with the use of sedatives and anesthesia and I release the veterinarian and staff of responsibility in the consequences of their use. I authorize Central Providence Hospital to administer proper emergency medical intervention if the need should occur. *

Please initial

I understand that my pet must be picked up by 4pm unless prior arrangements are made. The hospital closes at 5pm and pets here after 5pm will have to stay overnight or for the weekend at a minimum fee of $25/night (weekday) and $50/night (weekend). *

Please initial

I understand that overdue core vaccinations will be updated and necessary parasite control will be administered if needed.

Please initial

I authorize Central Providence Veterinary Hospital to perform a complimentary nail trim during the procedure.

Please initial

I understand that the contact person listed above will be responsible for making medical and financial decisions for my pet and family. *

Please initial

I understand that as a part of this procedure, fur may be shaved from one or both front legs for sterile IV placement and/or from the body for surgical procedures.*

Please initial

I HAVE READ THE FORGOING, UNDERSTAND WHAT IT SAYS, AND AGREE.

Owner Signature*

Date*

Date

Printed Name of Owner (may be different than primary contact person):

ANESTHESIA AND SURGERY/SEDATION FORM

PREPARATION INFORMATION: