Anesthetic Release Form Cheyenne

Owner's Name *

First Name Last Name

Pet's Name *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Pet's Age *

Pet's Gender *

Breed *

Color of Coat *

Email

example@example.com

Procedure being performed: *

Our doctors use one of the safest anesthetic and surgical protocols available to minimize any risk to your pet. No anesthetic or surgical procedure, however, is completely without risk. Although modern veterinary anesthetics are generally considered safe, problems can still potentially occur. Complications from an anesthetic may range from mild nausea to prolonged recovery due to an organ problem (kidney or liver) to, very rarely, death. This is why our doctors include pre-surgical blood tests and, in some cases, additional screening tests prior to all anesthetic procedures. These tests are important in helping to identify patients with underlying problems for which anesthesia may pose a greater risk.

For dogs: Did you give your dog Pepcid AC yesterday and this morning? *

Yes No Not Applicable

If Pepcid AC was not given, would you like us to administer a famotidine injection for a cost of $15.00? *

Yes No Gave Pepcid AC/Not Applicable

Would you like us to place a Home Again Microchip today? (The cost is $39.00) *

Yes No

Would you like your pet to have a complimentary nail trim? *

Yes No

I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the pet described above and I have the authority to execute this consent. I authorize the doctor and assistants to perform the procedures listed above, including administration of pain relief medications, sedatives, and/or anesthetics, as well as any necessary medical, radiological, surgical, nursing, diagnostic, and/or emergency care for the pet. I have been advised as to the nature of the procedure and the potential risks. I also understand that no guarantee of succesful treatment can be made. I understand the reasons for and the risks of the above procedure(s), and assume full financial responsibility. I have been informed that Cheyenne West Animal Hospital is not staffed 24 hours a day. I understand that if my pet requires overnight supervision post-surgically, my pet will be referred to the appropriate emergency hospital.

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