Owner's Name *

First

Last

Email *

Patient's Name *

Procedure *

Last Feeding *

Best phone number to contact you today *

I consent to receive SMS text messages from Animal Care Clinic. Msg & data rates may apply. Reply STOP to opt-out. *

Yes
No

Anesthesia Consent

I, the undersigned, certify that I am the owner, or an authorized agent for the owner, of the animal(s) listed above. I Authorize the Doctor(s) and staff of 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 and necessary and appropriate medical, surgical, diagnostic, nursing, and emergency treatments for my animal.

Animal Care Clinic offers the safest anesthetic and surgical procedures available for your pet. However, there is always an element of risk with any anesthetic procedure, and occasionally problems may occur during or after any medical or surgical procedure. For example, mild nausea, adverse drug reactions, prolonged recovery, and extremely rare, death may occur.

Animal Care Clinic uses "Isoflurane" as the general anesthesia agent for your pet. This provides superior anesthetic safety and smooth induction and recovery. We also require that all pets have blood tests prior to administering anesthesia. These tests help identify underlying problems that may increase risks to your pet during anesthesia and in the future.

Anesthesia Consent *

I have read and understand

Did your pet receive oral Cerenia the night before surgery? *

Yes
No

Is your pet having a dental procedure? *

Yes
No

Has your pet experienced any vomiting or diarrhea in the last 24-48 hours? *

Yes
No

Cardiopulmonary resuscitation, or 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 drugs. If my pet should suffer cardiac arrest, I request full resuscitation efforts with the understanding additional financial responsibility will result even if CPR measures are unsuccessful, resulting in loss of life. *

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

I have read and understand this form and accept responsibility for payment of all charges incurred and services provided to my animal by Animal Care Clinic. *

Clear Signature

Signature

Date *

Online Form

Anesthesia Release Form
Animal Care Clinic in El Cajon, CA