Sedation Consent Form

Sedation Consent Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date
I, the undersigned, certify that I am the owner/agent of the animal described above. I give Vetfield Animal Hospital & Mobile Vet permission to give/use anesthesia on my pet.

While there are risks associated with general anesthesia, be assured that Vetfield Animal Hospital & Mobile Vet will take every precaution to minimize risk by always performing the following:
- ✓ Physical exam prior to anesthesia
- ✓ Multi-parameter monitoring (blood pressure, EKG, CO2, heart/respiratory/temp)
- ✓ Intravenous (IV) catheter and fluid therapy
- ✓ Preoperative and postoperative pain control injections
- ✓ Endotracheal intubation and oxygen therapy
- ✓ Injectable and inhalant (Isoflurane or Sevoflurane gas) anesthetics based on your pet's age and specific medical needs.
Check mark the box if they apply to you

I understand the following additional procedures are optional, but highly recommendedPre-operative Bloodwork (recommended on all pets, required on animals >4 yrs old)Oral pain medications and antibiotics to go homePost-Op Laser Therapy for pain and inflammation reliefHeartworm test for dogs; FeLV/FIV test for catsIf you can't be reached, do you want the veterinarian to proceed at his/her own discretionDoes you pe have any history ofSEIZURES ?
I hereby authorize Vetfield Animal Hospital & Mobile Vet to perform such diagnostic, therapeutic and surgical

procedures as described above. The nature of such services has been described to me to my satisfaction. I realize

that there are risks involved with any anesthetic or surgical procedure and that no guarantee or warranty can be

made regarding the results or cure. I also authorize the hospital staff, in an emergency, to follow through with such procedures as are necessary for the well-being of my pet on a continuing basis until further communication with me. I have been given an estimate and understand that it is an approximation of planned procedures and the final bill may be more or less than this amount. I understand that I assume financial responsibility for a rendered.
Signature

Powered by Jotform SignClear
Should be Empty: