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Consent to Sedate Form

Owner Name:

Address:

Client Phone Number:

Pet's Name :

Patient ID:

Species:

Breed:

Sex:

Age:

Color:

Weight:

Contact Phone #:

Primary contact person:

Emergency Phone #:

Emergency contact person:

When was the last time the patient ate?

Is patient on any medications?

Yes

If yes, give the name of the medication, dosage and last time

administered.

What is the patient here for?

Special Instructions:

I hereby authorize performance of the above sedation on my pet. The nature of such service has been described to me to my satisfaction and I realize that no guarantee no warranty

can ethically or professionally be made regarding the results or cure. I understand that I assume financial responsibility for all services rendered, and that payment is due upon hospital discharge of the patient.

Signature of Owner or Authorized Agent:

Signature