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Owner’s Name *

Pet’s Name *

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I am at least 18 years of age and I am the legal owner of the animal described in this medical record. I am admitting my pet a sedated/anesthetic procedure to be performed by one of the Veterinarians at Best Friends Animal Hospital.

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Primary Phone Number

Secondary Phone Number

E-mail (optional) *

In the event your pet will need to stay overnight, what do you feed your pet and how much?

Sedated/Anesthetic procedure being done:

Other

In the event I cannot be reached at the numbers above I request: *

Does your pet have a microchip?

What is the microchip number? *

Has your pet eaten this morning?

If yes, Please explain *

Has your pet had morning medications?

list if any *

Does your pet need a prescription refill today?

Please specify

My signature below verifies the following:

A) The diagnosis, medical/surgical care and post surgical care has been described to my satisfaction.
B) A financial estimate has been prepared for me. I understand these expected costs are only estimates and that situations can arise that would alter the actual medical cost.
C) I accept that all medical/surgical procedures involve some risk. I understand that these risks include but are not limited to:
- 1) Sedation: I realize that some patients may have adverse reactions to anesthesia/sedation that may result in permanent injury or death.
- 2) Infections can complicate would healing: I realize that despite all precautions, a small percentage of patients may develop infections. I understand that these patients require additional medical care, which is not covered in my medical estimate.
- 3) Unexpected outcomes: I understand that no promises or warranties can be given. I realize that complications can occur at any point during the procedure or the healing process. I accept that some complications can prevent my pet from achieving the outcome I had hoped for.

Signed

Signature of Responsible party

Date

Sedation Consent Form

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