HPVC Anesthesia Release

Anesthetic Release Form
To ensure the utmost safety and comfort of your pet, we perform a pre-operative blood panel, place an IV catheter for fluid thearpy and to allow medication administration and give full pain medications with all of our anesthetic procedures. Patients are also fully monitored with state of the art equipment and trained nursing staff while under anesthesia.

I, the owner or agent of the animal identified below, hereby authorize Hancock Park Veterinary Clinic to perform the following procedure, which will require anesthesia or sedation.
Procedure*

Spay/NeuterDental under AnesthesiaLocal Mass removalMass removal under anesthesiaOther
Name*

First NameLast Name
Phone Number to best reach you*
Pet Name*
Risks/Complications- I acknowledge that there are certain risks to any anesthetic/sedation/surgical procedure including but not limited to post-operative bleeding, infection, bloat, and death. I also acknowledge that there is an increase risk of bleeding in pregnant, in heat, or obese females and that there may be an additional charge for these conditions at the surgeon's discretion. I understand the inherent risks of anesthesia and release Hancock Park Veterianry Clinic, doctors, and staff of any liability.
If in the unlikely event that life saving measures need to be taken while my pet is under the care of HPVC:*

I DO want any/all measure performed to save my petI do NOT want heroic measures taken to save my pet
Heroic measures may include oxygen treatment, IV fluids, addition medications, and/or CPR. Additional fees of at least $150 will be charged if this is necessary.

Again, in the unlikely event these measures are need, we will contact you as soon as the pet is stable.
Please read:
Latest pick up time is 5:30pm. You will receive a call when your pet is ready for pick up if earlier than 5:30pm. If pick up time is after 6pm, an additional fee will be added for late pick up
Name*

First NameLast Name
Date*

MonthDayYear
DateHourMinutesAM/PM Option
Signature*

Clear
Should be Empty:

Anesthetic Release Form

Please read: