Authorization forSedation/Procedure Form

Make the most of your next appointment by saving time! Before your appointment, fill out your authorization for sedation/procedure form from any device at any time.

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Authorization for Sedation/Procedure Form

Pet Information

Pet's Name *

Today's procedure is: (example: lump removal, exam, etc.) *

If mass removal(s), confirm location

If TPLO or amputation, confirm limb (right/left, back/front)

The last time that my pet had any food before arriving was

Nothing since 10pm
Nothing since midnight
Nothing since 6am
Ate today
Other

Contact Information

Owner's Name *

First

Last

Email *

Phone *

Note: In case of an emergency and/or prior to additional procedures, you will be contacted by telephone. Please keep yourphone with you.

Additional Phone

Secondary Contact:

First

Last

* This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

Secondary Contact Phone *

Additional Services Desired While Patient Is Sedated

My pet is on the following medications

Please select any/all that you would like us to provide while your pet is sedated

Implant Microchip
Nail Trim
Clean Ears
Express Anal Glands
Sanitary Clip (rectum, genitals)
Remove Lumps (specify location of lumps below)
Other (specify below)

Please specify where the lumps are located *

Please specify the additional service(s) you'd like provided to your pet

In addition to the planned procedure and pre-operative diagnostics, we offer the following options added to your pet’s plan to help ensure safety and comfort (see additional cost).

Electrocardiogram (ECG) reviewed by a cardiologist prior to the procedure:

Pre-anesthetic anti-nausea injection: ask for accurate pricing based on weight

Complimentary Nail Trim

Anal Gland Expression:

Post operative sedatives: ask for accurate pricing based on weight

CPR Consent: In the event of a catastrophic emergency, please elect what life-saving measures you would like performed so that we may be in accordance with your wishes:(these are at additional cost)

Do NOT perform CPR on my pet
Basic life support and CPR measures (chest compressions, artificial respiration)
Advanced life support and CPR measures (IV medications, fluids, etc)

Authorization

I certify that I am the owner, or authorized agent for the owner, of the above pet. I authorize the doctor on duty and assistants to perform the above prescribed procedures including administration of sedatives and/or anesthetics, as well as any necessaryand appropriate medical, surgical, nursing, diagnostic, and/or emergency care for the above pet. I understand that Rancho San Carlos Pet Clinic is not a 24 hour hospital. Should an overnight stay be necessary, direct observation will not be available. If the above pet needs observation we recommend transfer to a 24 hour emergency hospital. I understand that during these procedures great care is taken to ensure my pet’s health, but unforeseeable conditions may occur that necessitate an extension or variance in the procedure(s) defined above. I authorize Rancho San Carlos Pet Clinic to perform any additional diagnostic, treatment or surgical procedure(s) deemed necessary for medical or surgical complications or any unforeseeable circumstances. I accept responsibility for any result in additional charges. The nature of the procedure and the potential risks have been explained to me and I understand the procedure(s) to be performed. I understand that some risks always exist with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. I will not hold Rancho San Carlos Pet Clinic, the veterinarians, or any team member liable for any complications that may arise. No warranty or guarantee has been stated or implied to me as to the results or cure afforded by these treatments or procedures.My approval of this consent form indicates that any and all my questions have been answered to my satisfaction. I understand thatI am assuming full financial responsibility for all services rendered at the time my pet is discharged from the hospital. *

I have read, understand, and authorize

We place the highest priority on ensuring you feel comfortable with the plan for your pet’s care and fully understand the authorizations above before giving your consent. If you have any questions or need clarification on any of the choices, please contact the hospital so a medical team member can review the form with you prior to completing it. As always, thank you for entrusting us with your pet’s care!

I HAVE READ AND FULLY UNDERSTAND THIS ANESTHESIA CONSENT FORM *

Signature of Responsible Party *

Clear Signature

Print name *

First

Last

Date *

Name