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Sedation & Anesthesia Form

Sedation & Anesthesia Form

Name: My Vet Animal Clinic
Address: 13 E 2nd St, Eureka, MO, 63025, United States
Telephone: 636-938-3239
Price range: $

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 636-938-3239 for a faster response.

Client's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Patient Name *

Patient Breed *

Patient Sex *

Male
Neutered Male
Female
Spayed Female

Patient Age/Date of Birth *

Patient Color *

Please list all anesthetic/surgical procedure(s)to be performed. Please indicate any and all requests (e.g., neuter, dental cleaning and mass removal (specify location), dental extractions, microchipping, etc.): *

I, the undersigned owner or agent of the pet identified above, authorize the staff of My Vet Animal Clinic to perform the above procedure(s).

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. Dental procedures may warrant tooth extractions.

I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies.

If unable to contact me, the staff may or may not have my permission to proceed with life-sustaining procedures. *

Yes, I give my permission.
No, I do not give my permission.

I consent to pre-surgical bloodwork. *

Yes, I consent.
I decline pre-surgical bloodwork

Histopathology is the microscopic examination for the surgically removed tissue used to study the manifestation of disease. Basically, histopathology lets us know what type of tumor is present on your pet and what that tumor is capable of doing. Our histopathology specimens are sent to a diagnostic lab and are read by board-certified histopathologists. *

I consent to histopathology on my pet’s mass
I decline histopathology

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 have read and fully understand the terms and conditions set forth above.

Signature *

Date *

Phone number(s) at which owner can be reached today or tomorrow: *

convenience

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Questions?

If you should have any questions, please feel free to use the form below, and we'll get back to you as quickly as possible. If you need immediate assistance, please call us directly at 636-938-3239.

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