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🐾 Sedation Release Form

Cherry Creek Veterinary Hospital

7955 Watt Avenue

Antelope, Ca 95843

916-349-2755

Client ID:

Client Name:

Patient ID:

Patient Name:

Phone Number where you can be reached at TODAY

When was Pet last fed?

Please write the procedure will we be doing today:

Vaccines needed today:

Untitled checkboxes field

Yes. I would like to Microchip (Pet Name) for an additional cost of $71.40

Untitled checkboxes field

No. I would not like to microchip (Pet Name) at this time.

I, the undersigned owner and designated agent, hereby authorize the staff of Cherry Creek Veterinary Hospital to perform a procedure requiring general anesthesia and/or sedation of my animal. I understand that there are potential life threatening risks associated with anesthesia and/or sedation. 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/sedation and surgical complications.

Owner or Authorized Agent:

Signature