Sedation Release ver 1.0

I, ______am leaving my pet ______ for the following

please print your name print your pet’s 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.