Sedation Consent Form

Please fill out this form to help us prepare for your pet’s procedure.

Client Name(Required)

First

Last

Phone(Required)

Email(Required)

Pet's Name(Required)

Today's Procedure (check all that apply)(Required)

Sedated Examination

X-Rays/Radiographs

Biopsy

Laceration Repair

Other

If other, please specify(Required)

Has your pet had any food past midnight last night? Please note, vomiting during and after surgery is very common and if they aspirate food/water they can have severe anesthesia complications, including death(Required)

Yes

Is your pet taking any medication?(Required)

Yes

Medication dose and time given(Required)

Pre-Anesthetic Bloodwork

Anesthetic procedures and those performed under sedation carry an inherent risk. Undoubtedly the importance of the procedure outweighs the potential for complications. Pre-sedation bloodwork will help minimize the risks during anesthetic and sedated procedures. By testing blood chemistries and hematology values, we can better evaluate the status of your pet's major organ systems. Highly recommended for pets over 6 years of age.(Required)

Yes, I want pre-anesthesia bloodwork, and I accept the additional cost.

No, I declined pre-sedation bloodwork.

Optional Services That Can Be Performed While Pet Sedated

Microchip permanent identification ($85)(Required)

I consent to the placement of a microchip.

I decline the placement of a microchip.

My pet is already microchipped.

Nail trim ($25)(Required)

Yes, I would like my pet to receive a nail trim.

No, I would not like my pet to receive a nail trim.

Exam for health concerns ($71)(Required)

No, I have no health concerns that I would like examined on my pet.

Yes, I would like an exam on my pet.

Please describe your concern(Required)

Additional services/products (vaccines, professional services, medication/preventative refills, etc.)

Sedation Risk

I, the undersigned owner or agent of the pet identified above, authorize the staff of Veterinary Medical Center of Fort Mill to perform the above procedure(s).

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. In the event that life saving treatments are needed:(Required)

I elect to proceed with basic life supporting treatments and CPR

I DO NOT elect to proceed with basic life supporting treatments and CPR

Please initial to authorize your selection for life-saving treatment(Required)

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.

I also assume full responsibility for any additional expenses incurred after the sedated/surgical procedure is performed, such as follow-up radiographs, re-check physical exams, and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions.

I have read and fully understand the terms and conditions set forth above.

Phone number at which owner can be reached before/after procedure(Required)

Alternate phone number at which owner can be reached before/after procedure

Signature(Required)