Anesthesia Authorization Form

Save time during your appointment. Complete your required anesthesia authorization form online from any device at any time before your visit.

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Anesthesia Authorization Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet before your visit.

Pet's Name *

Date of Procedure

Owner *

First

Last

Phone Number *

Email *

Surgery or Procedure(s) to be performed:

What time did your pet last eat?

Is your pet on any medication? *

Sedation and General Anesthesia:
We will monitor your pet’s heart rate, respiratory rate, blood oxygen, blood pressure, and EKG during surgery. This along with pre-anesthetic blood screening reduces many of the risks of surgery. 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 is initiated. I accept that veterinary medicine is an inexact science and that no guarantee of successful treatment has been made. While all types of anesthesia involve some risk, major side effects and complications are rare. Some risks are related to and may increase in frequency depending on the pets’ overall health, age, and their unique responses to anesthetic drugs. Complications of anesthesia include but are not limited to unexpected drug reactions, corneal ulcerations, tracheal injury, esophagitis, blood clot formation, lung injury, and death. Our greatest concern is the well-being of your pet.

Should some unexpected life-saving emergency care be required and the attending veterinarian is unable to reach me (select one and initial) *

I Authorize Camden Village Animal Hospital to perform life saving treatments on my pet. This may include the administration of medications, chest compressions, oxygen, ventilation and other emergency measures deemed medically appropriate. Camden Village Animal Hospital will make every attempt to contact me in the event of an emergency situation. I understand that I will be responsible for additional charges incurred.
I do not authorize Camden Village Animal Hospital to perform life saving treatments on my pet. I authorize the attending veterinarian to minimize pain and suffering and to make every attempt to contact me and guide me in the management of my pet’s care.

Initial *

Authorization

I verify that I am the owner (or authorized personal for the patient) of the pet listed and approve the procedure above to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian.

Signature of Owner or Authorizes Personal *

Clear Signature

Anesthesia Authorization Form

Anesthesia Authorization Form

Authorization

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