Sedation Consent Form printable pdf download

Date ______________________

SEDATION CONSENT FORM

I, ____________________________, am at least 18 years of age and I am the legal owner of the animal described in this

medical record. I am admitting my pet (name) ______________________ a sedated/anesthetic procedure to be performed by

one of the Veterinarians at Best Friends Animal Hospital.

Phone numbers: (1st) _______________________________________ (2nd) _____________________________________

E-mail (optional) _____________________________________________________________________________________

In the event your pet will need to stay overnight, what do you feed your pet and how much?

____________________________________________________________________________________

Sedated/Anesthetic procedure being done:

______X-rays

______Ear Flush

______Abscess

______Other __________________________________________________

In the event I cannot be reached at the numbers above I request:

The doctors/staff continue with all appropriate medical care as needed.

Discontinue medical care until I can be reached.

Does your pet have a microchip?…………….………………………………………………………. YES

Has your pet eaten this morning? ……………………………………………………………………. YES

Has your pet had morning medications (list if any) ………… YES

NO _______________________________

Does your pet need a prescription refill today?.…

Yes

Please specify ______________________________

My signature below verifies the following:

A) The diagnosis, medical/surgical care and post surgical care has been described to my satisfaction.

B) A financial estimate has been prepared for me. I understand these expected costs are only estimates and

that situations can arise that would alter the actual medical cost.

C) I accept that all medical/surgical procedures involve some risk. I understand that these risks include but

are not limited to:

1) Sedation. I realize that some patients may have adverse reactions to anesthesia/sedation that may result in

permanent injury or death.

2) Infections can complicate would healing. I realize that despite all precautions, a small percentage of patients may

develop infections. I understand that these patients require additional medical care, which is not covered in my

medical estimate.

3) Unexpected outcomes. I understand that no promises or warranties can be given. I realize that complications can

occur at any point during the procedure or the healing process. I accept that some complications can prevent my pet

from achieving the outcome I had hoped for.

SIGNATURE ________________________________________________________ DATE __________________________

Thank you for allowing us to care for your pet!

Sedation Consent Form