Date of procedure *

Owner's Name *

First

Last

Email *

Pet's Name *

Procedure to be performed *

Was your pet fasted today? *

Yes
No

If not, what time was their last meal? *

Did or will your pet receive any medications before being dropped off? *

Yes
No

If so, please list medications *

The phone number(s) where you can be reached today *

Owner's DOB *

*This is required by the DEA in the case we prescribe a controlled substance for your pet

Sedation Information

As a full service veterinary hospital, we are pleased and proud to offer you the best medical care available to your pet. Your pet's health is of utmost priority to our dedicated staff, and we take all possible precautions to ensure their safety and comfort. Although rare, unexpected complications with sedation can occur.

Sedation Consent Waiver

I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent. *

I have read and understand

The nature of the procedure and the potential risks have been explained to me and I understand the procedure(s) to be performed. I understand that some risks always exist with 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 and all my questions have been answered to my satisfaction. *

I have read and understand

I hereby request ABC Veterinary Hospital Pacific Beach to administer sedation for my pet. While ABC Veterinary Hospital Pacific Beach provides the highest quality of medical services, I understand the risks and understand that the veterinarians and hospital team will do everything possible to minimize any risks. Notwithstanding the risk, I request the surgery and waive any and all claims of damage against ABC Veterinary Hospital Pacific beach, its officers and employees, in the event of injury or death of my animal. *

I have read and understand

Flea Treatment

For the health and safety of all of our hospitalized pets, all pets housed at our facility must be free of fleas. If fleas or evidence of fleas are found on your pet, an oral rapid-acting flea treatment will be administered (Capstar) at the owner's cost ($19-$22).

Additional elective procedures offered (please check services that you would like performed)

Elizabethan collars ($15-25) - Highly recommended with most surgeries. These collars dramatically reduce the risk of your pet removing bandages and sutures that may result in additional surgery/cost to you. Please note: soft "donut" collars are not recommended.
Nail Trim ($18-$25)
Anal Gland Expression ($33)
Microchip Implantation ($71)

Cardiopulmonary Resuscitation (CPR) Directive

I understand ABC Veterinary Hospital Pacific Beach requires a CPR status when my pet is left in their care. I acknowledge that the attending veterinarian or staff members of ABC PB will make every effort to contact me regarding treatment in the case of this unforeseen event. The initial cost of CPR, Oxygen and Emergency Injections start at approximately $800.

CPR means “Cardio Pulmonary Resuscitation” and is the treatment (resuscitation) of a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet who has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of a pet with no heartbeat.

DNR means “Do Not Resuscitate.” This means that if a pet stops breathing or his/her heart stops, no effort will be made to attempt to revive the pet, and the pet will die.

I am the owner / agent of this pet and... *

I AUTHORIZE CPR and Emergency Efforts for my pet
I DO NOT AUTHORIZE CPR and Emergency Efforts (DNR) for my pet

I understand that I am assuming full financial responsibility for all services rendered at the time my pet is discharged from the hospital. *

I have read and understand

Signature *

Clear Signature

Today's Date *

ABC Veterinary HospitalSedation/Drop Off Consent Form

Sedation Information

Sedation Consent Waiver

Flea Treatment

Cardiopulmonary Resuscitation (CPR) Directive

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