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Anesthesia/Sedation Admitting Form

Date

Pet's Name

Client's Name

Age

Patient's Sex

Did your pet have breakfast or any treats this morning?

Did your pet have breakfast or any treats this morning?
A
B

If yes, what time?

Is your pet allergic to any medications?.

Is your pet allergic to any medications?.
A
B

If yes, please list.

Is your pet on any medications?

Is your pet on any medications?
A
B

If yes, please list.

Does your pet have a history of having seizures?

Does your pet have a history of having seizures?
A
B

Has your pet had difficulty with anesthesia in the past?

Has your pet had difficulty with anesthesia in the past?
A
B

Do you have an e-collar at home that will fit your pet?

Do you have an e-collar at home that will fit your pet?
A
B

Pre-Anesthetic Blood Work: Advances in anesthesia and anesthetic monitoring techniques have made routine procedures relatively safe, with low rates of complications. However, occasional problems can occur due to preexisting conditions that are not evident during routine physical examinations. To minimize problems, our veterinarian staff strongly recommends your pet to be screened prior to anesthesia. Mandatory for pets over 7 years old.

Pre-Anesthetic Blood Work: Advances in anesthesia and anesthetic monitoring techniques have made routine procedures relatively safe, with low rates of complications. However, occasional problems can occur due to preexisting conditions that are not evident during routine physical examinations. To minimize problems, our veterinarian staff strongly recommends your pet to be screened prior to anesthesia. Mandatory for pets over 7 years old.
A
B

CPR/DNR - in case of an emergency

CPR/DNR - in case of an emergency
A
B
IV Catheter
*depending on the procedure being done there may be a IV catheter placed for fluids and
administering medications. If this is needed we will have to shave a spot on your pets arm*
I certify that I am the owner, or authorized agent for the owner, of the above animal. I hereby
consent to and authorize the doctors and staff at this veterinary practice to admit this pet, perform the procedure(s) described above, and administer medications, anesthesia, surgical
procedures, tests, and or treatments that the doctors deem necessary for its health, safety,
and well-being while being under their care and supervision. Should some unexpected life-saving emergency care be required and Acorn Hill Animal Hospital cannot reach me, the
staff at this practice has my permission to provide such treatment and I agree to pay for such care.
I have been advised of the nature of the procedure(s) and the potential risks and
benefits. I understand that veterinary medicine is an inexact science and that no
guarantee of successful treatment can be made.
I acknowledge that I am responsible for payment in full for the above procedure(s) and treatments at the time my pet is discharged.

Signature of Owner or Authorized Agent

Signature

The phone number(s) you can best reach me at today are: