Anesthesia Release Form
Any questions? Please call us at 363-6363.
__________________ __________________ __________________ __________________
Client
Patient
Age
Date
PLEASE READ CAREFULLY AND SIGN
Although Town and Country Veterinary Hospital takes every precaution and uses up-to-date monitoring devices, I understand that there are always potential risks using anesthesia or performing surgery on an animal. I further understand even with extreme care, rare adverse reactions, which are unpredictable, may occur with any sedation procedure. These reactions may include cardiac arrest, respiratory arrest, and death. __________ (Initial).
 
I give my permission to have my pet sedated if necessary for treatment. __________ (Initial).
 
Like you, we are greatly concerned with the well being of your pet. Your pet is scheduled for anesthesia and/or surgery today. Before putting your pet under anesthesia, we will perform a full physical examination. However, we recommend a pre-anesthetic blood profile to be performed in order that we may maximize patient safety and alert the doctor to the presence of dehydration, diabetes, and/or kidney or live disease, which could complicate the procedure. These conditions may not be detected unless a pre-anesthetic profile (PAP) is performed. These tests are similar to those your own physician would run were you to undergo anesthesia. In addition, the results of these tests may be useful later to develop faster, more accurate diagnoses and treatments in the event that your pet's health changes.
This blood panel is available for $44.50 
[ ]  Please complete the blood work you recommend prior to surgery on my pet. If abnormalities are found, please contact me at the phone number listed below.
____________________________________ ____________________________________
Signature of Pet Owner
Owner's Phone Number
[ ]  I have elected to refuse the recommended pre-anesthetic blood work at this time and request that you proceed with anesthesia. I understand there are always risks when using anesthesia or performing surgery on an animal.
____________________________________ ____________________________________
Signature of Pet Owner
Owner's Phone Number