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Anesthesia Release Form
Animal Care Clinic in El Cajon, CA

Save time at your next appointment! Please complete your required Anesthesia Release Form online from any device at any time before your visit.

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Anesthesia Release Form

Please complete this form completely and accurately so that we can get to know you and your pet(s) before your visit. If this is an emergency or your pet requires immediate attention, please call us at 619-670-8700 for a faster response.

Owner/Agent (O/A) *

First

Last

Email *

Pet’s Name *

Procedure *

Species & Breed *

Was food withheld? *

Any vomiting, diarrhea, or decreased appetite recently? *

If yes, please elaborate: *

Has your pet had any previous anesthesia? *

If yes, were there any problems? If so, what were they? *

Does your pet have any medical conditions? *

If yes, please elaborate: *

Please list any medications your pet is currently taking & when the last dose was given

Additional services (please read if applicable today):

DENTAL: If we will be performing a dental on your pet today, we will clean, polish, and fluoride the teeth. If diseased teeth are found, do we have your permission to extract? (This will be an additional charge). If you’d like a call first, you must have your phone on you as no extraction will be performed without your express permission. *

BIOPSY: If your pet is having a lump removed, would you like a biopsy? *

PAIN MEDICATION: If pain medication is needed, do you have any at home? *

If yes, what type and strength? *

SEDATIVES: If your pet is high energy, we often recommend taking home a prescription of sedatives which can help with the recovery process. Would you like a prescription for sedatives? *

E COLLAR: If an E collar is needed, do you have one at home? *

MICROCHIP: A microchip is a permanent form of identification in your pet. Would you like a microchip today? *

FECAL: We recommend a yearly internal parasite exam (fecal). Would you like that performed today? *

I, the undersigned, certify that I am the owner, or an authorized agent for the owner, of the animal(s) listed above. I authorized the doctor(s) and staff of the Animal Care Clinic to perform the procedures listed above and/or on the estimate for my animal. I also authorize the administration of pain-relieving, sedating, and anesthetizing medications as deemed necessary and appropriate by the doctors and staff as well as any medical, surgical, diagnostic, nursing, and emergency treatments needed for my animal. *

I have read and understand

I understand all reasonable precautions will be taken while my pet is under anesthesia and that Animal Care Clinic strives to offer safe anesthetic protocols and surgical procedures for my pet. I understand, however, that no warranty or guarantee has been made as to the result or the cure. I also understand that there is always a risk with any anesthetic procedure, and occasionally problems may occur during or after any medical or surgical procedure. These include but are limited to mild nausea, adverse drug reactions, prolonged recovery, and in extremely rare cases death may occur. I understand that in the event of unforeseen complications, all necessary actions (as deemed by the doctors and staff) will be taken for my pet’s well being. I also understand that I will be financially responsible for all medical treatment, care, and medications given to my animal by Animal Care Clinic. The risks of anesthesia or any procedures performed today have been explained to my satisfaction, and if not I will clarify with staff members. *

I have read and understand

Cardiopulmonary resuscitation (CPR), is the emergency treatment used for cardiac and/or respiratory arrest. This means that a patient’s heart has stopped beating and/or the patient has stopped breathing. If these events occur and CPR is not instituted, the patient will die. CPR includes manual chest compressions, intubation with manual respiration, oxygen supplementation, intravenous fluids, and the administration of emergency medications. If my pet should suffer cardiac or respiratory arrest, I request full resuscitation efforts with the understanding I will incur additional financial responsibility even if CPR measures are unsuccessful, resulting in loss of life. I also understand that instituting CPR does not guarantee success. *

Yes, I authorize CPR for my pet
No, Please do not resuscitate my pet in the event of cardiac or respiratory arrest.

I have read and understood this form as well as circled the appropriate answers to the best of my knowledge. I accept responsibility for payment of all charges incurred and services provided to my animal by Animal Care Clinic. All charges are due at the time of service. *

I have read and understand

Signature of Owner/Agent *

Clear Signature

Signature

Phone Number *

Date *

Have a question?

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We care for your pet family!

We look forward to seeing you soon!
If you need immediate assistance, our contact information is below.

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Find Us

2650 Jamacha Road
Suite 159
El Cajon, CA 92019

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Contact Us

619-670-8700
animalcareclinicsandiego@yahoo.com

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Our Hours

Mon–Fri: 7:30am–7:00pm
Sat & Sun: Closed

Online Form

Anesthesia Release Form Animal Care Clinic in El Cajon, CA

Anesthesia Release Form

Anesthesia Release Form
Animal Care Clinic in El Cajon, CA