Consent For Anesthesia OR
Sedation Form

Let’s spend the time comforting you and your pet on the day of surgery. Please fill out this form ahead of time so we can prepare for your pet’s surgery.

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Consent For Anesthesia OR Sedation Form

Please fill out this form as accurately as possible prior to sedation or anesthesia.

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Today’s Date:

Date of Procedure:

Client Full Name:

Pet’s Name:

Planned anesthetic, sedative and/or surgical procedure(s) to be performed:

I certify that I am the owner of the above-described animal and authorize the staff of Scotts Valley Veterinary Clinic to perform the above procedure(s). I understand that some degree of risk exists with anesthesia, sedation and surgery and I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before the procedure is initiated.

While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of the planned procedures. With the understanding of these risks, I agree to release Scotts Valley Veterinary Clinic from any liability associated with an adverse or unexpected outcome which include but are not limited to post-operative complications, infection, failure of incision integrity, progression of metabolic or systemic disease, or death. I agree to follow post-surgical/sedation and treatment instructions to the best of my ability.

Should medical complications arise requiring emergency treatment and the veterinarian is unable to reach me by immediate phone call, the staff at Scotts Valley Vet Clinic has permission to provide such treatment, and I agree to pay for such care which may include emergency treatment and procedures up to $600.

I understand that no veterinary personnel are present during nighttime hours and/or weekends. If I desire that my pet have constant supervision when this facility is closed, I elect to pick up my pet and transport him/her to a local 24-hour clinic where overnight veterinary supervision is available, or pick up my pet and provide such care in my home, in which case if against medical advice, I accept all risks of adverse effects.

I have read and signed a detailed estimate of charges for the planned procedure(s) listed above and agree to make full payment for services rendered when the patient is released/discharged from the Scotts Valley Vet Clinic. Every effort will be made to inform me of any changes in my pet's treatment plan and to gain authorization, which might cause an increase in this estimate.

Do you have any hospitalization, anesthetic, sedation or surgical concerns or questions

Primary Contact Name

Phone Number

Alternate Contact Name:

Phone Number

Primary Email Contact for the Day:

Name of Contact Planning to pick up the Patient from the Clinic:

This contact is planning to pay for the medical treatments/surgeries rendered today:

Signature

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