Owner's Name *

First

Last

Phone *

Email *

Pet's Name *

Authorization For Sedation *

I, the undersigned, certify that I am the owner, or authorized agent for the owner, of the pet listed above. I authorize the doctor on duty and assistants to perform the recommended procedures including administration of sedatives and/or anesthetics, as well as any necessary and appropriate medical, surgical, nursing, diagnostic, and/or emergency care for my pet. I have been advised as to the nature of the procedure and the potential risks. I also understand that no guarantee of successful treatment can be made.
I understand that Tell Tail Veterinary Urgent Care is not a 24 hour hospital. Should an overnight stay be necessary, direct observation will not be available. If my pet needs observation we recommend transfer to a 24 hour emergency hospital.

In case of an emergency and/or prior to additional procedures, you will be contacted by telephone. The phone number(s) where you can be reached TODAY is

Phone *

Phone

Notes about my availability: *

The last time my pet ate any food was *

If other, please explain: *

Authorization for Life-Saving Treatments

In the event of a catastrophic emergency, please select what life-saving measures you would like performed. (please select one option below) *

Do Not Resuscitate (DNR) If my pet's heart or breathing stops, I do not want CPR performed. I understand this means my pet will pass away naturally.
CPR If my pet's heart or breathing stops, I authorize CPR, including chest compressions, emergency medications, intubation, oxygen support, and additional treatment based on doctor discretion. * Estimated cost: average $1,000-$3,000

- I understand that if my pet does not respond within a reasonable time, efforts will stop.
- I understand that the chance of successful recovery is not guaranteed, and that efforts may still be unsuccessful.

Sedation/Anesthesia Information

- An intravenous catheter may be placed to provide immediate access to your pet’s circulatory system, this allows for rapid administration of drugs should an emergency situation arise.
- All pets undergoing surgery will receive pain injections. Post-operative pain management is a concern with virtually all surgical procedures. Most procedures merit at-home oral medication for several days after surgery and will be dispensed at the veterinarian's discretion.

Authorization and Risk Assessment

Authorization and Risk Assessment *

The nature of the procedure and the potential risks have been explained to me and I understand the procedure(s) to be performed. I understand that some risks always exist with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedure(s) are initiated. My signature on this consent form indicates that any and all my questions have been answered to my satisfaction.
I understand that during these procedures great care is taken to ensure my pet’s health, but unforeseeable conditions may occur that necessitate an extension or variance in the procedure(s) defined above. I authorize Tell Tail Veterinary Urgent Care to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical or surgical complications or any unforeseeable circumstances. I accept responsibility for any result in additional charges.
I understand the risks and understand that the veterinarians and hospital team will do everything possible to minimize any risks. I will not hold Tell Tail Veterinary Urgent Care, the veterinarians, or any team member liable for any complications that may arise. No warranty or guarantee has been stated or implied to me as to the results or cure afforded by these treatments or procedures.
I understand that I am assuming full financial responsibility for all services rendered at the time my pet is discharged from the hospital.

Signature *

Clear Signature

Today's Date *

Sedation Consent Form