Sedation Consent From. 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 No Is your pet taking any medication?(Required) Yes No Medication dose and time given(Required) Pre-Sedation BloodworkAnesthetic 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-sedation bloodwork , and I accept this additional cost. No, I declined pre-sedation bloodwork. BiopsyIf a biopsy is being performed, then sending the sample to the lab for histopathology testing will provide important clinical information regarding your pet's health to determine if additional treatment is needed. (Note: This may already be included in your treatment plan.)(Required) Yes, I consent to the biopsy and the associated lab fee. No, I decline the biopsy. Optional Services That Can Be Performed While Pet SedatedMicrochip permanent identification ($85)(Required) I consent to the placement of a microchip. I do not consent to the placement of a microchip. My pet already has a microchip. 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) 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. Ear cleaning ($25)(Required) Yes, I would like my pet to receive an ear cleaning. No, I would not like my pet to receive an ear cleaning. Additional services/products needed (e.g., vaccines, medication/preventative refills, other services, etc.) E-CollarAn e-collar (Elizabethan collar) is recommended for all procedures that involve an incision. It is critical to prevent self-trauma to the incision, which will delay healing and or lead to incision correction surgery. An e-collar has been included with your estimate for surgery. Some owners may prefer an e-collar that fits against the neck (similar to a human neck brace). Please speak to VMC staff if you wish to choose a different e-collar. If you decline an e-collar for your pet's recovery, it is against medical advice, and incision repairs are 100% client financial responsibility.(Required) Yes, I would like an e-collar and I understand the importance of it for my pet's recovery. I decline an e-collar for my pet's recovery and I understand the above risks and responsibilities. I already have an e-collar for my pet. If you already have an e-collar, please bring it with you when you drop your pet off the morning of their procedure. It is very important for us to ensure that the size and fit are appropriate. Chill Pills (Dogs Only)Restricted activity is required for proper healing for 7-10 days. This can be difficult for our young and/or active/energetic canine patients. We have an oral medication that acts as a "chill pill" and helps your pet calmly handle the restricted activity. This can prevent incision complications which may incur additional charges and is very safe for dogs. Our veterinarians will evaluate each pet to ensure this is a safe, suitable option.(Required) No, my pet does not require Chill Pills. Yes, Chill Pills will assist my pet with the recommended activity restriction. I do not have a dog. Sedation RiskI, 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 sedation and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. I understand that the attending veterinarian will make every effort to contact me regarding treatment in case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures.(Required) I elect to proceed with life saving treatments. I DO NOT elect to proceed with life saving treatments. 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 procedureSignature(Required) Reset signature Signature locked. Reset to sign again Date(Required) MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.