Sedation Authorization and Release Form

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Sedation Authorization and Release Form

Pet Name *

Owner's Name *

Email *

Procedure

Date

Consent and Authorization Statements

Brief History

Time of last meal?

List any current medications or supplements you pet currently receives:

Did your pet receive any medications today?

Please list any known medical conditions or concerns:

Please intial

I understand and authorize that my pet's procedure requires sedation.All precautions will be taken to ensure the safety of my pet. However, I have been informed of the possible risks associated with sedation, and that I am responsible for all associated charges.
The nature of these operation(s) or procedure(s) has been explained to me, and I understand what will be done.

Emergency Intervention

I have also been informed that there are certain risks and complications associated with any operation or procedure of this type. In the case that complications occur:

Green Code: Begin lifesaving interventions, including CPR and drug administrations as deemed necessary by the veterinarian. I agree to assume financial resposibility for all emergency services rendered.(minimum4100.00)
Red Code: I decline lifesaving interventions or drug therapies

Full payment is expected at the time of discharge.

I have read and understand this authorizaion and consent

Signature

Clear Signature

Numbers where you can be reached today:

1) Contact No. *

2) Contact No.

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Sedation Authorization and Release Form