Download Authorization for Sedation/Anesthesia

AUTHORIZATION FOR SEDATION/ANESTHESIA
(Please read carefully before signing)
I, ________________________, am presenting my pet _______________ to Acredale
Animal Hospital for_____________________________________________________.
I understand this procedure will require sedation or general anesthesia and I am aware of
the risks involved therein. Depending on the type of agent used risks includes aggression,
low blood pressure, central nervous system or respiratory depression, or heart
arrhythmias which may even lead to respiratory or cardiac arrest and death. These risks
are minimal in patients with no pre-existing health problems but increase if the patient
has pre-existing disease such as obesity, heart disease, kidney disease, liver disease,
diabetes, or epilepsy. I understand that pre-anesthetic testing is available to me before my
pet is sedated or anesthetized. These tests include ECG or blood tests. They may help to
screen for the pre-existing diseases mentioned above.
_______________________
__________________
(Owners signature)
___________________________
(Telephone number)
(Date)
______________________
(Times available)
Additional procedures/diagnostics/treatment: Additional information is available regarding
these items:
PetLink Microchip
( ) Yes. I want my pet to receive the PetLink Microchip. Cost $53.10 Includes fee for
permanent registry with PetLink which we will send in.
( ) No. I do not want my pet to receive the PetLink Microchip.
Pre-anesthesia blood work
( ) Yes. I elect to have pre-anesthetic blood work done. These tests will cost an additional
$58.20. If any significant abnormalities are detected the Doctor will call you to discuss options
prior to sedating your pet.
( ) No. I decline pre-anesthetic blood work. I understand there may be an underlying health
problem that has not been detected.
Post operative pain medication
Your pet will receive a pre-anesthetic pain control injection and will be prescribed post operative
pain medications as needed based on the procedure. The medications will cost approximately
$15.00-$50.00 depending on the weight of your pet.