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🐾 Anesthesia Release Form

Please complete this form before your pet’s appointment. Your answers help us provide the best care possible.
Phone Number where you can be reached at TODAY:

When was {PET NAME} last fed?

Please list current medications, including administration of HAPPY PACK medications, when applicable:
Medication name:
Medication name:

Medication name:

Medication name:

Does your pet have any of the following problems:  
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{NAME} will be undergoing general anesthesia for a surgical procedure today.  In order to recognize any underlying abnormalities {NAME} may have, we will be performing a pre-surgical blood profile if it has not already been done.
For safety reasons, all anesthetized animals will be monitored with an ECG/Pulse Oximeter.  An IV catheter will be placed and your pet will receive IV fluids during the surgical procedure.

Additional Recommendations:

Would you like any additional services to be done while your pet is under anesthesia?

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Help protect an important member of your family.  Microchipping is the most complete nationwide system for recovering lost or stolen pets.  It utilizes a tiny microchip about the size of a grain of rice, which is implanted between the animals shoulder blades.  Individual personalized code numbers are registered in a national database.  When a lost pet arrives at a participating animal shelter or veterinarian, the code is scanned and the owner is identified immediately.

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I, the undersigned owner and designated agent hereby authorize the staff of Cherry Creek Veterinary Hospital to perform a procedure requiring general anesthesia of my animal.  I understand that there are potential life threatening risks associated with anesthesia.  I understand the veterinarian will make every effort to contact me in the case of unforeseen circumstances regarding treatment of an emergency situation, but if unable to contact me, she/he will proceed with any life sustaining procedures.  I am aware of the risk involved and release Cherry Creek Veterinary Hospital from any legal and financial responsibilities arising from anesthetic and surgical complications.


I understand that Cherry Creek Veterinary Hospital does not have 24 hour staffing available and that after clinic hours my pet will be unsupervised. 


***Please note that any pet admitted into the hospital with fleas will be treated with topical and/or oral medication at the owner's expense.***

Owner or Authorized Agent
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