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Sedation Consent Form

Owner's Full Name:(Required)

Owner's Address:(Required)

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Owner's Phone Number:(Required)

Owner's Email:(Required)

Pet's Name:(Required)

Pet's Species:(Required)

Canine (Dog)

Feline (Cat)

Pet's Sex:

Pet's Breed:(Required)

Pet's Date of Birth or Approx. Age:(Required)

Your pet will be undergoing sedation for a procedure by a veterinarian. In order to recognize any underlying abnormalities your pet may have, we recommend having a pre-surgical blood profile run on your animal. This consists of a CBC, which will check blood cells, and an ALT, ALKP, CREA, GLU, TP and BUN, which will check for blood glucose, kidney and liver enzymes.

These blood tests will help us to assess the health status of your pet more completely and determine if there are any additional precautions we need to take before undergoing anesthesia. We do require a blood profile for geriatric pets over 5 years old. We hope you understand the need for these tests and the benefits your pet may receive from them.

Please select(Required)

I DO wish to have the pre-surgical blood profile done on my pet.

I DO NOT wish to have the pre-surgical blood profile done on my pet.

I am unsure and would like to speak to a veterinarian before deciding.

Owner's Name:(Required)

Print Your Full Name

Owner's Signature:(Required)

Sign Your Full Name

Today's Date:(Required)

Date your pet will be sedated:(Required)

Emergency Phone Number:(Required)

Additional comments/notes:

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