Anesthesia/Sedation Consent

Pet Information

Owner's Name*

First Name Last Name

Patient Name*

Appointment Date*

Procedure

Contact Information

Primary Phone Number*

Email*

Primary Contact Name*

First Last

Do you prefer text communication to the number above?*

Yes
No

Secondary Phone Number

Secondary Contact Name

First Last

Do you prefer text communication to the number above?

Yes
No

Medical Intake

Is your pet on any medications?*

Yes
No

Please list medications here:*

Does your pet have medical conditions or medication/vaccine reactions?*

Yes
No

Additional Services

Additional Services Desired?*

The following additional services are available while your pet is here and/or under anesthesia. Please check any the additional services that you would like to have done with this procedure. Please see your estimate for prices.

Other:

In the event that life saving services or resuscitation is needed, is the veterinarian authorized to perform these services (at additional cost) at their discretion?*

Yes
No

The veterinarian may recommend services above the estimate that are indicated in relation to today's procedure, such as additional extractions during a dental. We will attempt to contact you, but if you cannot be reached immediately, is the veterinarian authorized to perform these services (at additional cost) at their discretion?*

Yes
No

Consent*

By submitting this form, you agree to the following statements.

I hereby consent and authorize Central Texas Animal Hospital, its doctors, agents, employees, an representatives to perform the above listed procedure on my pet.

I also authorize them to utilize diagnostics, treatment, surgical, anesthetic, and sedative protocols as they deem necessary.

I hereby certify that I am informed of possible risks and complications associated with these procedures, including death.

I also certify that no guarantee or assurance has been made as to the results that may be obtained.

I am the owner or agent of this patient and have the authority to execute this consent.

I have read and fully understand this authorization for medical and/or surgical treatment.

I assume financial responsibility for all charges incurred to patient, consent to release of medical information and authorize payment to: Central Texas Animal Hospital.

CAPTCHA

English Version

Spanish Version

Pet Information

Contact Information

Medical Intake

Additional Services

Contact Us

Hours