Anesthesia Authorization

Client Name

Client Email

Patient Name

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My pet was fasted twelve hours prior to admission

Pre-Anesthetic Panel was completed

If yes, please enter the date that the Pre-Anesthetic Panel was completed

I am the owner (or agent for the owner) of the above described animal and have the authority to execute this consent.

I authorize the following treatments:

I authorize the use of post-operative pain analgesics.

I authorize the use of appropriate anesthetics and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.

I have been advised as to the nature of the procedure(s) or operation(s) and the risks involved. I realize that results cannot be guaranteed.

I understand that the above test, treatment, and procedure may vary based on individual patient needs. In some cases, additional tests or procedures may be required to reach an accurate diagnosis and achieve the best and safest treatment. Other unlisted c

I would like you to insert a microchip for identification in my pet while under anesthesia. I understand an additional fee will be added to my invoice for this service.

Has your pet received any medication(s) this morning?

If yes, please list:

Signature

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Signer Name

Anesthesia Authorization

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