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Sx/Sedation Release form

Save time during your appointment. Complete your sx/sedation release form online before your visit.

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Sx/Sedation Release form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Contact Information

Owner: *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Mobile Phone *

Patient Information

Patient Name *

Patient Age *

Breed *

Color *

Sex *

Microchip Number

For the purpose of:

{Consult Presenting Problems}

Consent For Sedation

I am the Owner / Authorized agent of the pet described above. I consent for the patient described above to have sedation. *

Yes

I agree to this procedure, the risks of the procedure have been explained to my satisfaction, and my questions regarding this procedure have been answered to my satisfaction. *

Yes

The above contact information is accurate and I will be available by phone at all times today. Should I not be available when/if the doctor calls me for any reason, including but not limited to emergency care decisions, during said procedure I give consent for Her/Him to proceed and do what She/He feels medically necessary for the above listed patient and understand that I am authorizing further medically necessary treatments and the fees associated with them no matter the outcome. *

Yes

Today's Date *

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Sx/Sedation Release form

Sx/Sedation Release form

Contact Information

Patient Information

Consent For Sedation

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