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Sedation Consent

Please fill out the following form before your pet’s sedated procedure.

Allied Veterinary Care - Sedation consent

Pet Information

Pet's Name(Required)

Contact Information

Owner's Name(Required)

First Last

Email(Required)

Phone(Required)

Additional Phone

Secondary Contact(Required)

First Last

* This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

Secondary Contact Phone(Required)

Today's procedure is: (example: lump removal, exam, etc.)(Required)

Additional Services Desired While Patient Is Sedated

Please select any/all that you would like us to provide while your pet is sedated

Implant Microchip

Nail Trim

Clean Ears

Express Anal Glands

Sanitary Clip (rectum, genitals)

Remove Lumps (specify location of lumps below)

Other (specify below)

Please specify where the lumps are located(Required)

Please specify the additional service(s) you'd like provided to your pet(Required)

Authorization

Anesthesia/Sedation Authorization(Required)

I authorize anesthesia/sedation for my pet. The nature and risks of this procedure have been explained to me. I understand some risks always exist with anesthesia and/or sedation, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any questions have been answered to my satisfaction.

I have read, understand, and authorize

Anesthesia/Sedation Authorization(Required)

I authorize Allied Veterinary Care to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical complications or otherwise unforseen circumstances. I understand there are rare complications associated with any anesthetic procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks and understand the veterinarians and hospital staff will try to minimize such risks. I will not hold Allied Veterinary Care, the veterinarians, or any staff member liable for any complications that may arise.

I have read, understand, and authorize

Payment due upon services rendered.(Required)

I have read, understand, and agree.

I HAVE READ AND FULLY UNDERSTAND THIS ANESTHESIA CONSENT FORM(Required)

Yes

Signature of Responsible Party(Required)

Date(Required)

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

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Contact Us

Email: [email protected]
Phone: (703) 987-6826
Fax: (703) 997-0436
Mailing Address: 8647 Richmond Hwy, Suite 237, Alexandria, VA 22309
*Please note: This is a mailing address. We come to you!

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