PetForward Anesthesia and Surgery/Sedation Consent Form

Pet Name:

Owner Name:

Procedure(s):

Best contact name and number for today:

**It is very important that we are able to reach you. Please have this phone with you and on.

Alternate contact number for today:

My pet last ate at:

Last times medications were administered:

Do you have any additional questions or requests for today?

CONSENT TO TREAT - please INITIAL each box

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 consequence of their use. I authorize PetForward Urgent Care to administer proper emergency medical intervention if the need should occur.

Please Initial

I understand that my pet must be picked up at the arranged time, at the latest. We do not staff overnight therefore no pets are to spend the night with us alone.

Please Initial

I understand that PetForward Urgent Care does not extend credit and agree to pay this account in full at the time of services rendered. A deposit will be required.

Please Initial

I authorize PetForward Urgent Care to perform a complimentary nail trim during the procedure.

Please Initial

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

Please Initial

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

Please Initial

I understand my pet may need restricted activity, medications, and rechecks after the procedure.

Please Initial

RESUSCITATION AUTHORIZATION

Definitions:

CPR - Cardiopulmonary resuscitation. This is the treatment for a pet without a heartbeat or not breathing and involves chest compressions, intubation, and manual ventilation to provide oxygen to the pet. CPR efforts are not guaranteed to revive a patient, and if they are successful, that pet has a high chance of another arrest event within the next 4 hours which would require additional care and monitoring at a 24-hour facility.

DNR - Do not resuscitate. If this is selected, resuscitation efforts will not be made, and the pet will die if cardiac or respiratory arrest occurs.

In the event of an unexpected life-threatening emergency, I hereby request PetForward Urgent Care to perform... (please initial one)

CPR: I understand that CPR will be attempted but a positive outcome is not guaranteed. I agree to pay additional charges associated, even if above the estimate provided.

Please Initial

DNR: I understand that CPR will not be performed, and that death is imminent.

Please Initial

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

Owner or Responsible Party Signature

Date

ANESTHESIA AND SURGERY/SEDATION CONSENT FORM