Authorization for Sedation / Anesthetic Procedure Form Authorization for Sedation / Anesthetic Procedure Owner's Name * Owner's Name First First Last Last Pet's Name * Phone Number * Email * Preferred method of contact for updates * Email Call Text Procedure(s) to be performed Elective procedure(s) while your pet is in our care Microchip Microscopic Fecal Exam 4dx Test (hwt + tick borne illnesses) Feline FELV/FIV Test Post Op Laser Therapy Flush and Clean ears Anal Gland Expression Presurgical ECG Mass Removal Vaccinations Would you like us to biopsy the mass? Yes No By checking the box below, I have confirmed the location of the mass(es) to be removed (area is shaved) * I agree Current medications and dosages DENTISTRY: I understand that the veterinarian will perform a thorough dental exam under anesthesia to assess the condition of my pet’s teeth and determine the need for extractions. I acknowledge that, depending on the severity of the dental disease, additional extractions may be necessary, even if they were not originally planned. * Yes, I authorize all medically necessary extractions and do not need to be contacted. No, I do not authorize all medically necessary extractions and do need to be contacted first. I understand if I cannot be reached, I elect to let the Veterinarian proceed with medically necessary extractions and assume all financial responsibility associated. No, I do not authorize medically necessary extractions. If I cannot be reached, I understand that by checking this, my pet will be woken up from anesthesia. *Please be aware that if you decline any needed procedures at this time, your pet would need a second anesthesic procedure at another time in order for those procedures to be performed. I understand I am authorizing NO extractions without my consent, and my pet will be woken up from anesthesia if I am unreachable. In the event of spontaneous arrest (heart rate, breathing, etc.), I elect the following (please select one) * CPR - Cardiopulmonary resuscitation (CPR) of a collapsed or unconscious patient is tailored to meet the needs of the individual, including but not limited to: IV catheter placement, IV fluids, emergency injectable medications, intubation and artificial ventilation, or chest compressions. (Estimated, but not limited to, $500. Not reflected in any estimate given) DNR - DNR “do not resuscitate”, this means that in the event of cardiac arrest, CPR will NOT be performed if the patient stops breathing, enters cardiac arrest, collapses, and/or becomes unconscious. Please read below and sign I hereby authorize American Animal Hospital to perform such diagnostic, therapeutic and surgical procedures as are, in their opinion, necessary and advisable for treatment and maintenance of my pet’s health and well being. The nature of such services has been described to me to my satisfaction and, while I expect all procedures to be done to the best of the abilities of the professional staff, I realize that no guarantee or warranty can ethically, or professionally, be made regarding the results or cure. I understand that I assume full financial responsibility for all services rendered, regardless of outcome. Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
