General Consent Form – With Sedation

Caretaker Name*

First Last

Pet's Name*

First

Phone Number*

Secondary Phone Number*

What is the reason for today's visit?*

Is the condition better / worse / the same?*

What symptoms are being seen?*

What medications is your pet currently taking?*

When were the medications last given? If they were stopped, when?*

Are there any other concerns you would like addressed with the doctor?*

Acknowledgement of Risks

I am the owner or agent for the owner of the above animal and have the authority to execute this consent. I hereby consent and authorize the pet to be hospitalized for examination and treatment.

Has your pet ever had any seizures?*

Procedural Risk Acknowledgement

Risks of the above procedure(s) include (but are not limited to) the following: 1. sedation complications including death 2. prolonged effects of sedation 3. corneal ulceration 4. elevation of third eyelid

I understand that because of unforeseen circumstances, the cost of rendered services may exceed the estimated cost. In this case, all charges are held as low as possible. The doctors and staff of Bay Area Animal Eye Care will be glad to go over itemization and explain any charges.*

Please Sign or Initial

I understand that it may be necessary, during the procedure or hospitalization, to provide emergency medical care in the event that I cannot be contacted. Therefore, I consent to and authorize the performance of such medical or surgical interventions as are necessary and desirable in the exercise of the veterinarian’s professional judgement.*

Please Sign or Initial

I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.*

Please Sign or Initial

I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed.*

Please Sign or Initial

In the unlikely event of a cardiac or respiratory arrest during hospitalization or surgery, would you like the attending doctor to perform CPR to the best of our ability with the equipment available?*

Payment Acknowledgement

Payment may be made in the form of cash, personal check, VISA, or MASTERCARD. A fee of $35.00 will be added payable charges for returned checks. The balance must be paid in full before the animal will be released, as our policy does not permit delayed payments.

Please Enter Today's Date*

I have read and understand this authorization and consent.*

Please Sign or Initial

General Consent Form – With Sedation