Anesthesia / Sedation Release Form

At All Vet Care, your pet’s safety and comfort are always our top priorities. Before procedures that require anesthesia or sedation, we ask pet owners to complete our Anesthesia/Sedation Release Form so that we can review important information about your pet, discuss the planned procedure, and obtain your authorization for anesthesia services.

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Anesthesia / Sedation Release Form

Please complete this form prior to any procedure requiring anesthesia or sedation:

Patient Name *

Date of Procedure *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Owner Name *

First

Last

Email *

Patient’s Weight *

Please indicate weight in lbs.

Has your pet fasted today? *

When was the last time he/she ate or drank? *

Please list any current prescription medications, over-the-counter medications, and/or supplements (including vitamins). Include the strength, route of administration, and time administered. *

In your own words, please describe the specific area on your pet’s body and the procedure you understand is being performed today (e.g., “left hind leg TPLO surgery,” “mass removal on right shoulder,” etc.): *

Pre-Anesthetic Blood Work: To provide the best possible care for your pet, we recommend pre-anesthetic blood work to check the functions of the liver and kidneys. These are the two organs that process the anesthesia. If you decline pre-anesthetic blood work, your signature on this document is in agreement that you will NOT hold All Vet Care, its doctors, or staff responsible in any way for the loss of your pet, assuming all other reasonable precautions have been taken. *

Microchip Implantation: Microchip implantation is always recommended to give you the best chance of being reunited with your pet if any unfortunate event takes place. This microchip will be the first thing shelters scan for whenever they find any lost pets. *

I authorize the use of appropriate anesthetics and any other medications used in my pet’s best interest. I have been informed about the nature of the procedure, including the risks involved. I fully understand the risks involved with sedation, anesthesia, and/or the surgery of my pet, and do NOT hold All Vet Care, its doctors, or staff responsible in any way for the loss of my pet, provided all other reasonable precautions have been taken. I understand that during the course of the procedure(s), unforeseen conditions may arise that may necessitate the performance of additional procedures. If the patient above is found to be infested with fleas, it WILL be treated during the procedure at the OWNER’S expense. Furthermore, I understand that payment is due at the time services are rendered, and I know I will be given an estimate upon request.

Unless otherwise instructed by the attending veterinarian, E-collars are necessary and required in order for surgical sites or affected areas to heal properly without self-inflicted irritation, trauma, or infection. By signing below, I confirm that I have read and understand this requirement. I acknowledge that if I choose not to use an E-collar as directed—whether by refusal or lack of follow-through—I accept full responsibility for any resulting complications and will not hold All Vet Care, its doctors, or staff liable in any way.

I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent. My signature below certifies that I am over eighteen years of age.

Signature *

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Today's Date *

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