AUTHORIZATION FOR SEDATION FORM

Pet Name:*

Owner Name:*

Contact Number(s) on Procedure Day:*

Alternate Contact Number(s) on Procedure Day:

**It is important that we can reach you. Please have your phone on and available. **

**Please note that the people listed above will need to make medical decisions on behalf of your pet and family**

Procedure:

Date of Procedure:*

No food should be offered after 9pm the night before the procedure. Please keep water available. It is helpful to remind everyone in the home. What time will your pet eat last before the procedure?*

What medications does your pet take? (Also, please let the team know what time they were last given at drop-off):

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

Additional requests or questions for procedure day:

OTHER RECOMMENDED ITEMS TO CONSIDER (Select Yes or No): Please note that the costs of these options were not a part of your original estimate.

ANTI-NAUSEA SUPPORT [$60 for pets under 65lb, $80 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, protect against vomiting during anesthesia, and return them to eating and acting normally as quickly as possible. This treatment offers significant benefits to many patients, and the cost is the primary reason it is not automatically included with our sedated procedures.

YesNo

PRE-ANESTHETIC TESTING [$150]: Chem10/CBC - Since drugs are removed from the body through the kidneys and liver and platelets are important for blood clotting, it is important to know that internal organ function and blood values are within normal limits. We prefer pre-anesthetic testing for all pets and require blood tests within 3 months for any pet 8 years or older.

YesNo

ACKNOWLEDGMENTS: (Read and Initial beside each statement, then sign at the bottom)

I understand that a veterinarian of Vet-REC: Veterinary Rehabilitation and Exercise Clinic will oversee my case, but that I will drop-off between 7:30 am and 8:00 am at Indian Trail Animal Hospital for this service. Pick-up will be after 2:00 am.

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 the veterinarian in charge of my pet's sedation to administer proper emergency medical care if the need should occur.

Please Initial

I understand that pre-payment will be taken at Vet-REC: Veterinary Rehabilitation and Exercise Clinic before the day of the procedure.

Please Initial

My pet is up to date on Rabies, DHPP, and Bordetella vaccines. I understand that if we do not have proof that these are current, my pet may not be allowed to drop-off.

Please Initial

I authorize the medical team 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 HAVE READ THE ABOVE, UNDERSTAND WHAT IT SAYS, AND AGREE.

Owner Signature*

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

Date