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Sedation/Pre-Anesthetic/Surgical Release Form

Sugar Land Veterinary Clinic

Contact's Name

Contact's Cell Phone Number

Contact's Email Address

Pet's Name

Schedule procedure for today

Was the patient overnight/today fasted?

Yes

Were any medications given last night or this morning?

Yes

Any pre-anesthetic diagnostics other than bloodwork required?

Name of The Person That Dropped Patient Off (& Will Pick Patient Up if Different)

BEST method of immediate contact during sedation/surgery

ATTENTION

We sincerely thank you for taking the time to complete this portion of this sedation/pre-anesthestic/surgical release form.

We are aware that this is a highly-sensitive subject matter, however, your answer is necessary in order to ensure that we are able to care for your pet in the way that you would like us to in all circumstances.

Thank you!

Please choose:

DNR - Do Not Resuscitate: If my pet’s heart or breathing stops, I do NOT authorize any medical intervention, or supportive treatments to be administered in order to save my pet’s life.

CPR- Cardiopulmonary Resuscitation: I authorize ALL resuscitative efforts, including surgery if deemed necessary, in the attempt to keep my pet alive. I acknowledge that there is no guarantee that these efforts will be successful. I will pay ALL costs incurred in the resuscitative efforts. These costs are NOT included in the initial estimate.

Signature

Client Consent For Anesthesia, Surgical, and Treatment Release

I am the owner of the above-named animal, and hereby authorize the services/treatments discussed with Sugar Land Veterinary Clinic (SLVC). I also authorize the use of anesthetic agents as are deemed necessary and appropriate to perform the above procedures.

I acknowledge and I understand that as a result of the performance of these procedures described above, there is a material risk that the patient may suffer from complications including but not limited to: infection, allergic reaction, blood loss, loss of function of limb or organ, paralysis or paresis, weakness, tissue scarring, brain damage, cardiac or respiratory arrest, or death, despite the efforts of SLVC to avoid such complications.

I also authorize the administration of such additional treatments and surgical procedures that are considered therapeutically and diagnostically necessary on the basis of findings during the course of evaluation and/or treatment. Any female patients that are in heat, pregnant, or have recently had a litter may incur additional charges.

I assume financial responsibility for all charges incurred on behalf of the patient.

I understand that all reasonable precautions against injury, escape, or death of the above pet will be used, however, I also understand that certain inherent risks are involved in carrying out any medical procedure which are beyond the control of the persons involved, especially in sick, debilitated animals. In the absence of gross negligence, I thoroughly understand that I assume certain risks and will not hold Sugar Land Veterinary Clinic (SLVC), it's employees, representatives, or agents liable or responsible in any manner or circumstances for these risks.

By signing below, I acknowledge I have read, or have had explained to me, and I understand this form, and I voluntarily consent to the performance of the procedures described or otherwise referred to herein.

I also confirm that failure to utilizing the Elizabethan Collar (E-collar) that has been provided for my pet after surgery may result in complications that I will be monetarily-responsible for SLVC correcting.