ECV - Anesthesia/Surgical Release Form

Name*

First NameLast Name

Pet's Name*

Breed*

Sex*

Age/Date of Birth*

Type of Surgery*

I certify that I am the owner of the above-named animal or the responsible party with the authority to execute this consent. I authorize the use of sedation/anesthesia for the above listed procedures. To help ensure the continued health of your pet, East Central Veterinarians requires that distemper combination and rabies vaccinations be up-to-date for dogs and cats.*

I acknowledge

Additional Authorization

During an anesthetic procedure it is important that our hospital can immediately (no voicemail) reach the authorized owner or person responsible for making decisions for your pet if anything occurs that is not planned. If you are unable to be reached, and additional procedures are necessary, your pet may have to undergo anesthesia again at a later date, with the full price of the procedure charged to your account. For the health and safety of your pet we will not keep a patient under anesthesia longer than necessary.*

I acknowledge

Cardiopulmonary Resuscitation (CPR) Directive

I understand East Central Veterinarians (ECV) requires a CPR status prior to the start of all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or anytime in our care. The starting cost of CPR is approximately $300.*

I DO AUTHORIZE CPR efforts for my petI DO NOT AUTHORIZE CPR (DNR) efforts at this time

Preanesthetic bloodwork screen: Please check one box.

Every surgical or anesthetic procedure involves risk. Blood screening is highly recommended for all pets prior to any anesthetic procedure. The anesthetic agent is removed from the body by the liver and kidneys, so it is very important to know before administering anesthesia that these organs are functioning normally. If organ or blood dysfunction is found, appropriate steps can be taken to help ensure the safety of your pet. It is important to understand that the presurgical/preanesthetic blood screening does not guarantee the absence of complications but serves to forewarn us of any underlying organ or blood abnormalities.*

I understand there is always risk with anesthesia and surgery, but I decline internal bloodwork screen at this time.Preanesthetic bloodwork was completed within the past 30 days that the veterinarian approved

Financial Authorization

I have been provided with an estimate and understand that this is an estimate, without complications. If complications arise, they will be charged out accordingly. I understand that if my pet is found to have external parasites (fleas, ticks, etc.), my pet will be treated and the cost of said treatment will be charged to my account accordingly. I understand that the balance on the account must be paid in full before my animal is released.*

I acknowledge

I agree further to indemnify and hold you harmless from and against any and all liability arising out of the performance of the procedures referred to above.*

Date*

Email*

example@example.com

ANESTHESIA / SURGICAL RELEASE FORM