Client Information

Owner's Name *

First

Last

Email *

Primary Phone *

Secondary Contact: *

First

Last

* This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

my Veterinary to

Secondary Contact Phone *

Pet Information

Pet's Name *

Today's procedure is: *

(example: lump removal, exam, etc.)

Additional Services Desired While Patient Is Sedated

Please select any/all that you would like us to provide while your pet is sedated:

Please specify where the lumps are located *

Please specify the additional service(s) you'd like provided to your pet *

Authorization

I authorize anesthesia and/or sedation for my pet. The nature and risks of the procedure have been explained to me. I understand that some risk is always associated with anesthesia and/or sedation, and I am encouraged to discuss any concerns I may have with my veterinarian before the procedure begins. My signature on this consent form indicates that all of my questions have been answered to my satisfaction. *

I have read, understood, and authorize the above.

I authorize Adirondack Veterinary Hospital to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary due to medical complications or other unforeseen circumstances. I understand that rare complications can occur with any anesthetic procedure. No warranty or guarantee has been given regarding the results or outcome of these treatments or procedures. I fully understand these risks and acknowledge that the veterinarians and hospital staff will make every effort to minimize them. I will not hold Adirondack Veterinary Hospital, its veterinarians, or any staff member liable for complications that may arise. *

I have read, understood, and authorize the above.

Payment is due at the time services are rendered. *

I have read, understood, and authorize the above.

By signing below, I confirm that I have read and fully understand this Anesthesia Consent Form. *

Clear Signature

Date *

Anesthesia Consent Form

Preparing for Your Pet’s Anesthesia Procedure

Client Information

Pet Information

Additional Services Desired While Patient Is Sedated

Authorization

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