Anesthesia Release Form

I hereby authorize the following procedure(s) to be performed by the admitting veterinarian, or designated associates and assistants:
List procedure(s) below:
There are risks associated with any anesthetic procedure. To help minimize the risk, a pre-anesthetic blood screen will be performed on all patients undergoing anesthesia, unless otherwise indicated by your veterinarian. Selected laboratory tests can help to assess your pet's ability to metabolize and eliminate the anesthetics we administer. In addition, the results may reveal hidden health conditions that could put your pet at risk while under anesthesia. Our mobile clinic laboratory is fully-equipped to perform these blood tests and have the results available prior to anesthesia.

NOTE: Intravenous (IV) catheters will be placed in all patients undergoing anesthesia. Placement of an IV catheter allows delivery of fluids to assist in maintenance of your pet's blood pressure, hydration and to assist their organs in metabolizing the anesthetic drugs more efficiently. Additionally, in the events an emergency situation develops, an IV catheter allows rapid access for drug administration. (A small area of hair may be clipped for IV catheter placement)
Please indicate if your pet is on any medication(s) or supplements
- Yes
- No
If yes; what drug and when last given
If problems unrelated to the authorized anesthetic procedure are found that require ELECTIVE correction, I may be reached at the following phone number(s)
Phone
Other Phone
If the clinic staff calls and cannot reach me by phone, please do the following:
- Do whatever is necessary at this time to avoid a second anesthetic procedure for additional work
- Do not perform any ELECTIVE procedure not previously discussed (tooth extractions excluded for dental procdures)
Email*
IF YOUR PET IS SCHEDULED FOR A DENTISTRY, PLEASE READ AND INITIAL BELOW*
I acknowledge that if I cannot be reached during a dental procedure and tooth extractions(s) are deemed necessary for my pet's overall health, the extraction(s) will be performed.
I understand the above anesthetic and surgical, diagnostic or therapeutic procedures may involve risk of complications, injury or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure. Furthermore, I authorize the clinic staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communication with me. I agree to assume financial responsibility for all routine and emergency services rendered.

Your signature below constitutes your acknowledgement, as the owner or owner's agent, that (i) you have read and agreed to the above, (ii) the procedure(s) have been explained to your satisfaction and that you have all the information that you desire, (iii) you have had the chance to ask questions, and (iv) you authorize and consent to the performance of the procedure(s) and to the administration of anesthesia.
Consent*
I understand and consent to the above.
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Anesthesia Release Form

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