Sedated Drop-Off with Anesthesia Consent

Please fill out the following regarding your pet you are dropping off

Owner Information

First Name

Last Name

Address

City

State

Zip Code

Phone number

Secondary phone number

Email

Patient Information

Pet Name

Species

Color

Breed

Age/DOB

Sex

Weight

Drop-Off Information

Where can you be reached throughout the day?

Reason for Visit:

If medication is sent home, which do you prefer?

Pills

Liquid

Please check one of the following

Please examine my pet and call me with an estimate prior to any treatments or diagnostics.

Please examine my pet and continue with any necessary treatments or diagnostics.

Sedation information

Thank you for choosing our veterinary hospital for your pet’s care. The following information will be used to help our veterinary team assess your pet prior to their preoperative exam and sedation.

Has your pet had any food past 8 p.m. last night?

Yes

Has your pet ever had any convulsions or seizures?

Yes

Has your pet ever had an adverse reaction to any medications, vaccines, or anesthesia?

Yes

Not Sure

Is your pet currently taking any medications?

Yes

List all medications

If yes, what time was medication last given

How was it given?

Does your pet have any chronic illnesses/diseases?

Yes

Is your pet current on vaccines and flea & heartworm prevention?

Yes

Do you want your pet microchipped while under anesthesia?

Yes

No - my pet is already microchipped

AUTHORIZATION: I represent/own the pet listed above and hereby authorize the veterinarians of the hospital to perform the above procedure(s). The nature and purpose of the procedure(s) has been explained to me and I understand that no guarantee exists as to the result or diagnosis and treatment of my pet.

I understand that my pet will be placed under general anesthesia or sedated for the necessary procedure, and understand that there are inherent risks associated with the use of general anesthesia and sedatives, including acute death.

I understand that Lange Animal Hospital and its employees are properly trained in the administration of sedatives and general anesthetics, and will properly monitor my pet during the course of the anesthesia and sedation. I give Lange Animal Hospital and its employees permission to use general anesthesia or sedation on my pet and release them from any liability should an adverse reaction occur. Should an adverse reaction occur, I give Lange Animal Hospital and its employees permission to perform all emergency procedures necessary to attempt to resuscitate and stabilize my pet. Should any problems occur, I can be reached at the phone number listed above.

I have had the fees outlined to me and agree to pay, in full, all such fees and charges at the time of discharge. These fees and charges may include those deemed necessary for medical or surgical complications or unforeseen circumstances, unless expressly declined previously on the consent form.

I also acknowledge, by signing this form that I have read and understand all information included on this form.

Authorization: Full Name

Authorization: Signature

Signature

Date

Emergency Treatment Authorization

If your pet is in critical condition and immediate treatment is needed, the initial stabilization period can cost $200 - $1000. This may include IV catheters, fluid, medications, x-rays, or other tests needed to assess your pet's condition. The doctor will talk to you about further treatment once your pet is more stable.

Emergency Treatment Authorization

Yes, I authorize the doctor to perform the needed emergency care.

No, I do not authorize such care and need to speak with the doctor before treatment is performed. I understand that the delay in treatment may further endanger my pet's life.

Initial Here to Confirm Treatment Authorization

CPR Authorization

*If a CPR choice is not marked, basic CPR will be initiated. One CPR is started, we will make reasonable efforts to contact you a responsible party. In the event you or a responsible party cannot be contacted, CPR may be discontinued if patient is not responding to efforts.

CPR Authorization

No resuscitative efforts (DNR)

Basic CPR (Chest compressions, assisted breathing, medications)

Initial Here to Confirm CPR Authorization Decision

Medical Consent

By submitting this form, I consent and understand the following: I consent to have my pet treated at Lange Animal Hospital. The preliminary diagnostic and therapeutic plans will be discussed with me along with the potential risks and costs. I understand that no guarantee has been made as to result or cure. I agree to be available by phone at all times during my pet's hospitalization for consultation with my pet's doctor(s). In the event that I cannot be reached, I authorize the doctors and staff to perform any procedures necessary for my pet's wellbeing. I agree to assume all financial responsibility for treatments done to my pet. I understand that final fees can be considerably different than an initial estimate. I understand that I can ask for an estimate at all times, and that I will be notified if any additional treatments or procedures need to be performed on Bella. I understand that billing is not available, and agree to pay the balance of all charges in full at discharge.

I, the above signed owner, agent of the owner, or Good Samaritan responsible for seeking veterinary care for the pet identified, certify that I am eighteen years of age or over.

Client Signature

Signature