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Online Pharmacy
Appointment
Online Pharmacy
Appointment
Home
About Us
Our Team
Testimonials
Services
Pet Health
Pet Insurance
Client Center
FAQs
Payment Options
Online Forms
What to Expect
After Hours/ Emergency
Our App
Contact
Anesthesia & Sedation Consent Form
Your pet’s safety is our top priority. To ensure a smooth procedure, please complete the Anesthesia & Sedation Consent Form online before your appointment.
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Anesthesia & Sedation Consent Form
Please enable JavaScript in your browser to complete this form.
Client Name
*
Email
*
Pet Name
*
Date
*
Is your pet currently taking any medication? Please list the medication, dose and time last given.
Please do not write "On File". We need to verify that the medications you are actually giving your pet matches what we have on file.
Has your pet had a steroid injection or taken any oral steroids within the last two weeks?
Yes
No
Was your pet given any sedatives this morning? (Gabapentin, Trazodone, Acepromazine, etc.) Please list the medication, dose and time last given.
Your pet needs to fast for 12 hours before sedation. When was your pet's last meal?
Does your pet have a history of seizures?
Yes
No
If yes, when was the last seizure? Is your pet on medication for this?
Does your pet have a history of any anesthetic complications? Please describe.
Do you want to receive text communications while your pet is here today?
Yes
No
While hospitalized, if your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatment. Please note that you will be responsible for any additional costs associated with emergency resuscitation and life-saving care.
YES, I would like my pet to be resuscitated and life-saving care be given, regardless of cost
NO, I would NOT like my pet to be resuscitated
I understand that during the performance of procedures for the above situation (s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedures, or even procedures different from those set forth previously. I hereby consent and authorize the performance of such procedures as necessary and desirable in the exercise of the veterinarian’s professional judgment. I have been advised of the nature of the services and procedures, as well as the risks involved, and I also realize that results cannot be guaranteed. I additionally authorize the use of appropriate anesthetics, pathologist examination of excised tissue(s) deemed appropriate by the veterinarian, and the administration of other medications, and understand that hospital staff will be utilized as deemed necessary by the veterinarian. I have read and understand this authorization and consent.
I agree to
pay all charges for services provided by Martinez Animal Hospital upon discharge
of my pet. Payments can be made by most major credit cards, CareCredit or cash. A credit card processing fee of up to 3% will be applied to all transactions made using credit/debit cards.
I understand and accept the clinic's cancellation policy, which
requires a minimum of 24 hours' notice for cancellations
; otherwise, a cancellation fee may apply.
I acknowledge the clinic's late policy, which states that while efforts will be made to accommodate appointments,
if I am more than 10 minutes late, Martinez Animal Hospital may not be able to provide services, and a $10 late fee may apply
.
Client Is the
Signature
Clear Signature
Date
In order to treat your pet in a timely manner, it is extremely important that we are able to reach you by phone throughout the day. Please leave a number that will be answered and checked.
Primary Phone Number
*
Alternate Phone Number
*
Message
Submit
