Sedation Consent Form

Save time at your pet’s procedure by completing our sedation consent form online or by printing a copy to bring with you.

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Sedation Consent Form

To ensure your pet receives the safest and most effective sedation during their procedure, please complete our Sedation Consent Form. This form helps us understand your pet’s medical history and specific needs.

You may use the PDF version by clicking the DOWNLOAD FORM button and then completing the printed form by hand. Please bring the completed PDF form with you for your appointment.

DOWNLOAD FORM

All sedated procedures include a pre-anesthetic physical exam, internal ear exam, nail trim, anesthetic monitoring, recovery monitoring.

Contact Information

Owner's Name *

First

Last

Pet's Name *

Email *

I can be reached today at the following number: *

If I am unable to be contacted, please contact: *

Is there a different party picking up? *

Cardiopulmonary Resuscitation (CPR): Informed Consent Cardiopulmonary arrest is when an animal stops breathing on its own or its heart stops beating. CPR can involve chest compressions, artificial breathing, and/or administration of drugs in an attempt to resuscitate the patient. CPR is not always successful. A great deal of this success depends on pre-existing conditions (age, overall fitness, prior illness, etc.) It is possible that a resuscitated patient will have suffered brain damage or other long-term ill effects from having been technically deceased for any period of time. In the event, that your pet stops breathing or the heart stops beating, we need your informed consent to proceed with or to withhold resuscitation efforts. CPR charges start at $50-200 and will be in addition to any amounts quoted for this procedure. Please choose the option below. *

Do whatever is necessary to stabilize my pet with NO cost limitations. I understand that I am responsible for ANY cost accrued and will be expected to pay the final bill in full regardless of the outcome.
Do whatever is necessary to stabilize my pet, but do not exceed a specific $ amount.
Do not resuscitate my animal in the event of cardio-pulmonary arrest.

Authorized Amount:

Additional Services

While your pet is under the comfort of anesthesia/sedation we offer the below services. Please check the box(es) you wish to have performed today.

Pre-anesthetic/Sedation History

When was the last meal your pet ate?

When did your pet last have access to water?

Is your pet on any medications or supplements? *

If yes, please provide the following details

Medication Name

Dosage

How often given

Last dose administered

Medication Name

Dosage

How often given

Last dose administered

Medication Name

Dosage

How often given

Last dose administered

I confirm that: *

The procedure has been explained to me by a Potlatch Veterinary Clinic staff member and I understand the risks associated with sedation

I confirm that: *

I am the owner of this animal and hereby am authorized to sign this release

I acknowledge that: *

If fleas are found on my pet, they will be treated with a 24-hour preventative, at my expense.

I acknowledge that: *

If any complications arise, I will not hold the veterinarians or any support staff at Potlatch Veterinary Clinic responsible

I understand that: *

If my pet has not yet been vaccinated against Rabies and is healthy, they will be vaccinated during the procedure today for $12

I understand that: *

100% of the low end of the estimate is due as a deposit at admit, and all remaining services rendered will be due prior to discharge with cash, check, Visa, Mastercard, Care Credit, etc

I consent to the following *

I hereby allow the veterinarians at Potlatch Veterinary Clinic to perform procedures on my pet as stated above

By signing this document I have carefully read and understand the terms and conditions set forth by Potlatch Veterinary Clinic and agree to all the above statements.

Signature *

Clear Signature

Today's Date *

Message

Sedation Consent Form

Sedation Consent Form

Contact Information

Additional Services

Pre-anesthetic/Sedation History

If yes, please provide the following details

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