Anesthesia/Sedation for an OutPatient Procedure Authorization Form

Initial for consent on the line provided

ANESTHESIA & PROCEDURAL CARE

I understand that my pet may require sedation or general anesthesia. Anesthetic protocols, drugs, and monitoring are selected based on my pet’s individual health status, age, and procedure. Despite appropriate planning and monitoring, all anesthetic and surgical procedures carry inherent risk. Veterinary medicine is not an exact science and outcomes cannot be guaranteed. I understand these risks.

RISKS & COMPLICATIONS

Potential risks and complications may include, but are not limited to:

• Adverse drug or anesthetic reactions

• Tracheal irritation including tears

• Organ dysfunction

• Cardiopulmonary complications

• Equipment failure

• Rarely, serious injury or death

HOSPITAL HUSBANDRY

If evidence of fleas are found on your pet, flea prevention will be administered for a fee.

ALTERNATIVES

I understand that reasonable alternatives, including no treatment, have been discussed with me. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

FINANCIAL RESPONSIBILITY

I agree to assume full financial responsibility for all services rendered. Treatment plans and estimates are not guaranteed. Payment is due at the time services are provided unless prior arrangements have been made.

NO GUARANTEE

I acknowledge that no guarantee or warranty has been made regarding the outcome, recovery, or results of any treatment or procedure.

CONSENT & AUTHORIZATION

By signing below, I certify that

• I am at least eighteen (18) years of age

• I am the legal owner or authorized agent for this pet

• I have read and understand this consent form

• I voluntarily authorize the procedures described above