Anesthesia Release Form "*" indicates required fields AUTHORIZATION AND CONSENT FOR HOSPITALIZATION/SURGERY I am the owner or agent for the below animal and have the authority to execute this consent and authorization of the following procedure/care:Owner's Name*Pet's Name*Procedure/Care*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.DOES YOUR PET TAKE ANTI-INFLAMMATORIES OR PAIN MEDICATION* Yes No WAS MEDICATION GIVEN TODAY, AND WHICH ONE (If not given today please type Not Given Today)?*DOES YOUR PET TAKE ANY OTHER MEDICATIONS?* YES NO IF YES, WHAT MEDICATIONS IS YOUR PET TAKING AND WHAT DOSE? (IF NOT VIEN TODAY, PLEASE TYPE: "NOT GIVEN TODAY."*HAS YOUR PET HAD A RECENT (WITHIN 2 WEEKS) STEROID INJECTION?* Yes No Has your pet been fasted?* Yes No Time of last meal?*Has your pet been given sedatives prior to appointment today?* Yes No If "Yes" what sedatives were given? Gabapentin Trazadone Acepromazine N/A What time were sedatives given? (If none were given, please type "N/A")DOES YOUR PET HAVE HISTORY OF SEIZURES?* YES NO IF YES, IS YOUR PET ON MEDICATION FOR SEIZURES? WHEN WAS THE LAST SEIZURE? (PUT N/A IF NOT APPLICABLE)*DOES YOUR PET HAVE HISTORY OF ANY ANESTHETIC COMPLICATIONS?* YES NO IF YES, PLEASE DESCRIBE THE COMPLICATIONS BELOW/WHEN THE INCIDENT TOOK PLACE?*While hospitalized, if your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatment. Would you like us to resuscitate your pet?* Yes, resuscitate No, do not resuscitate Enter your initials to consent to either resuscitation option*Date MM slash DD slash YYYY Procedure Consent* I give consent to this procedure.Cancellation/no show policy* By checking this box, I am acknowledging that I must give 24 hour notice of cancellation or reschedule. If I do not give notice, I am aware there is a $100 fee.Phone*****Please note, the phone number you provide on this form is the number we will be using to contact you while your pet is here. It is vitally important that you are reachable by phone******Signature