Sedation Release Form

Sedation Consent Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact for the day of your pet's procedure*
Contact Phone Number*
Please enter a valid phone number.

Patient Name*
Patient Breed*
Patient Sex*
Patient Color

In order to perform the recommended medical procedure your pet’s doctor has recommended sedation/tranquilization for your pet so that the procedure can be done properly, safely, and with little or no discomfort. Sedating a pet is generally considered to be very safe. Nonetheless each animal responds differently to sedative medications, and while there is little chance your pet will be “over-sedated”, it is possible that additional medications may be needed to deepen the sedative level or lengthen the sedative period so we can complete the planned procedure safely. Because this “extended sedation” would require additional medications and monitoring, additional costs may result. Your estimate should reflect this possible additional cost.

For the safety and comfort of our patients, and for the peace of mind of our clients, all patients are examined by the doctor priot to sedation. We also offer additional care above and beyond our minimum standards for those cases requiring more, as outlined below.
For additional safety we recommend the same pre-anesthetic blood test for pets younger than 8 years and IV fluids for stabilization under anesthesia. (please select option below)

Yes, I would like a pre-sedation blood panel -$75No, I would like to decline the Pre-Sedation blood panel
Additional Options*

Nail Trim - $27Microchip and registration $67None
I am the owner or authorized agent and hereby authorize County Line Veterinary Clinic (doctor and staff) to administer treatment and anesthesia as are determined to be necessary by the attending veterinarian. I understand the risks associated with sedative medications and I authorize the doctor to proceed with the sedation and the medical procedure as discussed. I do hereby release Dr. Fowler or the attending veterinarian and staff from any and all liability arising from these procedures for said animal. I am aware that veterinary service is not provided overnight. I further authorize emergency treatment if necessary without additional approval.
If your pet becomes ill, we will call the emergency phone number you provide. If no one can be reached and medical attention is required, do you authorize whatever services the doctor deems necessary?*
If you would like to treat up to a different amount than $500, please notate the amount below.
Initials*
Hospitalization/Overnight Care

I understand County Line Veterinary Clinic (CLVC) is not a 24 hour facility and does not have staff available to provide care outside of normal staffing hours. It is the recommendation of CLVC that all pets needing afterhours care or hospitalization be transferred to an afterhours care facility.

I agree to pay for all services at the time that they are rendered.*

Powered by Jotform SignClear
We will call or text to notify you when your pet’s dental is completed. Please check if you would like a call or a text*
Should be Empty:

Sedation Consent Form