Sedation Consent

OWNER INFORMATION

Full Name *

Email Address *

Best number to reach you at today *

Secondary Phone Number

PET INFORMATION

Pet's Name *

Does your pet have any known allergies?

If your pet is on any medication, please list them here and the time they were last given.

When did your pet last eat? *

Our greatest concern is the wellbeing of your pet. Before any sedation is administered, we will perform a complete pre-anesthetic examination to identify existing medical conditions that could complicate the procedure and compromise your pet’s health. There is always the possibility that a pre-anesthetic exam alone will not identify all health problems. This is why blood testing is recommended prior to anesthesia. This does not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require treatment.

Comprehensive Blood Panel: This is the most complete blood screen available using our in-hospital laboratory. This panel includes red blood and white blood cell counts, a check on kidney and liver function, and electrolyte levels.

If your pet has not had a comprehensive blood screening performed and reported as ‘normal’ within three months of their scheduled anesthesia/sedation, this test is recommended to do one.

I, or agent on owners behalf, by completing this form, hereby authorize Central Animal Hospital (or its agents or representatives) to perform the above procedure.

In regards to the statement above, please choose one of the following: *

Yes, I agree to have pre-anesthetic bloodwork testing completed.
No, I decline to have pre-anesthetic bloodwork completed.
I would like more information regarding pre-anesthetic bloodwork.

ACKNOWLEDGMENTS

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedures today. Any known risks will be discussed with you. However, very rarely emergencies do happen, and we want to know your preference if no one can be reached. Please check your preference: *

Please DO proceed with life-saving measures. I will accept all responsibility for all costs incurred.
Please DO NOT proceed with life-saving measures. I accept responsibility for all costs incurred.

I am aware that due to possible unforeseen emergencies, patients will be triaged resulting in my pet being in the care of Central Animal Hospital until later in the day than expected. *

I understand that there are inherent risks with sedation and that a guarantee of a successful outcome cannot be made. These risks have been explained to me as completely as possible within reason. I also understand that Central Animal Hospital will do their best to minimize these risks through pre-anesthetic blood testing, and using the most appropriate and safest anesthetic procedures and monitoring available. Furthermore, I agree to pay the fees for all services rendered at the time my pet is discharged from the hospital. Please sign recognizing that you have read and understand the risks. *

Signature *

Date *

Today

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *