Sedation Consent Form Kildaire

Owner Name *

First Name Last Name

Client ID

Animal Name *

Breed *

Age *

Sex *

Last meal eaten *

Special diet or dietary restrictions

Current medications and time last administered

Please list any known drug allergies or adverse reactions to medication(s)

Procedure to be performed under sedation *

Please accept the following *

I give my permission for my pet to be sedated for the above listed procedure. I understand that in order for my pet to stay in the hospital they must be current on all vaccines and must have recent bloodwork to assess organ function. I understand that even with excellent care and precautions, rare adverse reactions or events can occur with sedation. These events are extremely rare and can include but are not limited to: cardiac arrest, respiratory arrest, and death. I understand that an IV catheter may be placed and a small area on the leg will be shaved for placement

MICROCHIP: Would you like your pet to have a microchip placed while sedated? ($66.40 with surgery) *

Yes No Already Have One

Phone number where you can be reached between 8:30 a.m. and 3:30 p.m. *

Please provide email address or cell number if you would also like an email or text update when your pet is awake

Signature

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