Anesthesia Consent Form – Long Island City Veterinary Center

Client Name*

First Last

Pet Name*

First

Which one of our locations will you be going to?*

The Veterinarians at Court Square
East Side Animal Hospital
LIC Veterinary Center

Sedation & Anesthesia Consent

I hereby authorize this veterinarian to use sedation, tranquilization and/or general anesthesia as required on my pet, my pet, for the above treatment/surgery listed on this estimate. I understand that sedation or anesthesia poses a risk to my pet, regardless of health status. In the event of unforeseen complications, I give permission for the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. The anesthesia and relevant costs have been fully explained to me to my satisfaction.

In the event of an Emergency

In the event of an emergency and I am not able to be reached, I authorize and agree to pay for any service the Veterinarian determines is necessary to provide the highest standard of care to my pet. I acknowledge that I am the owner of the patient listed above or that I am authorized by the owner to make medical decisions on its behalf. In cases where the rightful owner fails to make payments for any medical decisions made, I will assume the financial responsibility for the decisions I have made.

To Keep All Pets Healthy

To prevent the spread of infectious disease, all in-house, out-patient, and boarders must be current on all vaccines and free of parasites. I understand this to be the strict policy of the hospital and authorize the doctors to provide my pet(s) with vaccinations and parasite control as needed. Any necessary treatments will be included on the invoice and due at the time of discharge.

Pre-Op Blood Acknowledgement

We require a pre-operative blood profile for any pet undergoing anesthesia to check their organ functions. We do so to minimize any anesthetic risks that are not physically visible on examination. If your pet has not had his/her blood profile completed within 30 days we will do it in-house before we proceed with anesthesia. There will be an added cost for the pre-operative blood profile done today.

Payment

We kindly request that ALL services are paid at the time they are provided. Client acknowledges personal financial responsibility for services received. For your convenience, we gladly accept Cash, Debit Cards, Visa, MasterCard, and American Express. Sorry, but checks are not accepted. DEPOSITS MAY BE REQUIRED FOR PETS BEING ADMITTED

I have read and understood all the above terms and give my consent*

Yes

Signature*

Date*

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DD

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