Client Name *

First

Last

Phone *

Email *

Pet's Name *

Today's Procedure (check all that apply) *

Other *

Has your pet had any food past midnight last night? Please note, vomiting during and after surgery is very common and if they aspirate food/water they can have severe anesthesia complications, including death. *

Yes
No

Is your pet taking any medication?

Yes
No

Pre-Sedation Bloodwork

Anesthetic procedures and those performed under sedation carry an inherent risk. Undoubtedly the importance of the procedure outweighs the potential for complications. Pre-sedation bloodwork will help minimize the risks during anesthetic and sedated procedures. By testing blood chemistries and hematology values, we can better evaluate the status of your pet's major organ systems. Highly recommended for pets over 6 years of age. *

Yes, I want pre-sedation bloodwork , and I accept this additional cost.
No, I declined pre-sedation bloodwork.

Optional Services That Can Be Performed While Pet Sedated

Microchip permanent identification *

I consent to the placement of a microchip.
I do not consent to the placement of a microchip.
My pet already has a microchip.

Nail Trim

Yes, I would like my pet to receive a nail trim.
No, I would not like my pet to receive a nail trim.

Ear Cleaning

Yes, I would like my pet to receive an ear cleaning.
No, I would not like my pet to receive an ear cleaning.

Additional services/products needed (e.g., vaccines, medication/preventative refills, other services, etc.)

Sedation Risk

I, the undersigned owner or agent of the pet identified above, authorize the staff of Veterinary Medical Center of Fort Mill to perform the above procedure(s).

I understand that some risks always exist with sedation and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure is initiated. I understand that the attending veterinarian will make every effort to contact me regarding treatment in case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures.

I elect to proceed with life saving treatments.
I DO NOT elect to proceed with life saving treatments.

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the sedated/surgical procedure is performed, such as follow-up radiographs, re-check physical exams, and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have read and fully understand the terms and conditions set forth above.

Phone number at which owner can be reached before/after procedure: *

Alternate phone number at which owner can be reached before/after procedure:

Signature *

Clear Signature

Date *

Online Forms

Sedation
Consent Form