Download Sedation Release - Briarcliff Animal Clinic of College Park College

Sedation Release ver 1.0
I, ______________________________ am leaving my pet ____________________ for the following
print your pet’s name
please print your name
procedure(s) that will require sedation:
1.___________________________________________________________________
2.___________________________________________________________________
3.___________________________________________________________________
Note: If growths are to be removed, please complete the back of this form.
I understand the risks involved with sedation. I understand that my pet could suffer injury or death due
to sedation complications.
I do hereby authorize the Briarcliff Animal Clinic to perform sedation on my pet, and declare that I am
the legal owner or authorized custodian of this animal. I release the Briarcliff Animal Clinic, Dr. Peter
J. Muller and all his agents or representatives of all legal responsibility for this animal.
Signature___________________________________
Date_________________
It is very important that we are able to contact you by phone while your pet is sedated.
On the day of the procedure, I may be reached at (_____)_____ - _________ or
(_____)______ - _________
Pre-Sedation_Bloodwork
Briarcliff Animal Clinic recommends pre-sedation bloodwork for all patients to identify any
underlying medical problems that may cause complications with your pet’s sedation.
[ ] CBC & Chemistry Profile (Glucose, BUN, Cr, ALP, ALT, TP) will be performed at an
additional cost.
[ ] CBC & Chemistries have been completed within 90 days of the procedure and are
available for the veterinarian’s interpretation.
[ ] I do not authorize pre-sedation bloodwork.
Pain Management
It is the ethical standard of this hospital to provide pain management to every pet when appropriate..
An injection may be administered to your pet prior to sedation and during the procedure to minimize
your pet’s discomfort. We may also provide oral pain medications for you to give at home. Pricing is
based on patient’s weight.
Microchips
Briarcliff recommends ‘microchipping’ your pet as a reliable form of permanent identification. Please
indicate below if you would like to have a chip placed in your pet while under anesthesia.
[ ] I do [ ] I do not authorize the placement of a microchip during surgery at an additional cost.
List time of pet’s last meal ___________am/pm
List any medication(s) that your pet is currently taking___________________________________,
and when it was last given___________ am/pm.
(Please TURN OVER)
Removal of Growths
If any growths, lumps, or tumors are to be removed, please mark their location(s) on the diagram
below.
Also, please mark the growth(s) on your pet using fingernail polish or permanent marker.