Exotic Sedation Consent Form Pet's Name * Owner's Name * First Name Last Name Email * It is imperitive that we be able to reach you in a timely manner while your pet is in the building today. Please list the primary phone number where you can be reached. Phone * (###) ### #### If we are unable to reach you, is there someone else we can contact regarding your pet? * If yes, please provide their information below. Yes No Emergency Contact First Name Last Name Emergency Contact's Phone (###) ### #### Please list the reason for sedation below * What is your pet's favorite food/snack? We recommend bringing a favorite food in a small bag to your appointment Has you pet experienced any of the following in the past two weeks? * Coughing Sneezing Vomiting Diarrhea None of the above Has your pet ever experienced any adverse reaction to medication? * Yes No Unsure Does your pet have any history of allergies or an allergic reaction? * Yes No Unsure If yes to either of the above, please provide more detail about your pet's medical history Please list any medications, supplements, topical treatments, or vaccinations that your pet has recieved in the past 72 hours Please provide details of the dosage and the time they were given Please list any of your pet's known health concerns, chronic diseases, and/or conditions * Please provide any further information that you would like us to know about your pet An estimate has been provided to me regarding my pet's sedation procedure today * Yes, I accept all costs provided within the estimate. No, however I accept any costs that may occur during my pet's visit today. No, I would like to see an estimate of the costs before proceeding with sedation today. I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by High Country Veterinary Hospital. I authorize the use of sedation and other medication as deemed necessary by the attending veterinarian * I accept these terms and conditions. Our greatest concern is the wellbeing of your pet. Before any sedation is administered, we will perform a complete pre-sedation examination to identify existing medical conditions that could complicate the procedure and compromise your pet’s health. There is always the possibility that a pre-sedation exam alone will not identify all health problems. This is why blood testing is highly recommended prior to sedation. This does not guarantee the absence of sedation complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require treatment. I have been advised as to the nature of this procedure and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation procedure, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges * I accept these terms and conditions. I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital * I accept these terms and conditions. In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference below Please proceed with basic cardiopulmonary resuscitation (CPR). I accept responsibility for all costs incurred. Please do not proceed (DNR) with basic cardiopulmonary resuscitation. I accept responsibility for all costs incurred. Thank you!
