Sedation Consent Form

All required fields are marked {*}

Pet Name:*
Client Name:*
First Last
Client Email:*
Client Phone Number:*
Can you be reached by text if we can’t reach you by phone?*
- Yes
- No
Blood work options:
Your pet will be undergoing general anesthesia plus a surgical procedure today. In order to recognize any underlying abnormalities your pet may have, we recommend blood work to check the function of the internal organs. Knowing how well these organs’ function are an important part to the safety of your pet while under anesthesia.
Please Select an Option below.*
- Yes, I have read the above statement and would like to perform a chemistry panel to evaluate the internal organ function, and a CBC to evaluate the red blood cells, white blood cells and platelet count to ensure clotting ability. This option is recommended to patients that are 6 years of age and older.
- Yes, I have read the above statement and would like to perform a chemistry panel to evaluate the internal organ function only. This is recommended for patients less than 6 years of age.
- No, I have read and understand the above statement and decline the pre surgical blood work.
Authorization for Sedation:
*
I verify I am the owner or authorized agent for the owner of the above-named pet and authorize the previously discussed procedure to be performed under anesthesia. I authorize the use of sedation and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure as directed by the veterinarian.
*
I have been advised as to the nature of this procedure to be performed and the risks involved. I also understand that there is always a risk associated with any sedation even in apparently healthy pets and have discussed by concerns with the veterinarian. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgement. I accept responsibility for any additional charges.
Has your pet ever had any previous reaction or issue with sedation?*
- Yes
- No
Name of Owner or Agent*
First Last
Signature of Owner or Agent*
Date Completed:*
MM slash DD slash YYYY
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Email
This field is for validation purposes and should be left unchanged.

Sedation Consent Form

Blood work options:

Authorization for Sedation:

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