Home » Hospital Procedure, Anesthesia & Medical Authorization Release Form

Hospital Procedure, Anesthesia & Medical Authorization Release Form

Date(Required)

Client ID #(Required)

Owner's Name(Required)

Pet's Name(Required)

Daytime Phone Number(Required)

Name of Contact(Required)

Attending DVM

Procedures(Required)

I am the owner of the described animal and hereby authorize the doctors of Appanasha Pet Clinic to perform the above treatment or surgical procedure on him/her today. The doctor has explained the nature and purpose of these procedures and treatments to me. Any further questions or concerns should be addressed at this time.

I consent to the administration of sedatives in the event that your pet may have increased fear, or anxiety OR anesthetic agents as deemed appropriate by the veterinarian for surgical or non-surgical visits. If unforeseen conditions arise (i.e. dental extractions) which call for procedures or treatments other than previously authorized services, I authorize such procedures or treatments if reasonable efforts to contact me for further consent are unsuccessful.

I understand that with any surgical or anesthetic procedure there is an element of risk, and complications may arise which cannot be predicted. I understand Appanasha Pet Clinic will do everything in the best interest of my pet and his/her safety. After recovery from anesthesia, patients are closely monitored throughout the day. They are securely placed in comfortable kennels for their stay overnight. Immediate rest and quiet time is an important part of your pet’s healing process. Please be advised that our staff is not available for monitoring throughout the night. We will contact you if we feel that overnight supervision is required.

Normal liver and kidney functions are necessary for recovery from anesthesia. If any problems exist, it is best to know about them prior to administering the anesthetic.

Before anesthesia, I would like blood test done to check on the health of my pet’s liver and kidneys. For pets over the age of 7 this is required unless blood work was done with in the last 6 months. If you need additional cost information please request or refer to your estimate.(Required)

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged.

Although uncommon, respiratory, and cardiac arrest are a risk for any pet that undergoes anesthesia. While we are attempting to contact you at the number you left, resuscitation efforts need to begin immediately. Should your pet have critical needs during the procedure or stay here, please list if you authorize the staff at Appanasha Pet Clinic to take every able action to prevent/reduce risk of death and incur the costs that may result from Resuscitation (CPR).(Required)

Yes, I authorize CPR and the cost that may accure

No, Do NOT resuscitate

Signature of Owner or Authorized Agent(Required)

Date(Required)

Full payment due at the time of service, To learn more about Care Credit as a payment option, follow the link to their site here

Name

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