Pet Information

Pet's Name *

Contact Information

Owner's Name *

First

Last

Email

Phone *

Additional Phone

Secondary Contact: *

First

Last

This person has your authority to consent to medical decisions regarding your pet's surgical care in the event we cannot reach you.

Secondary Contact Phone

Today's procedure is: (example: lump removal, exam, etc.) *

Additional Services Desired While Patient Is Sedated

Please select any/all that you would like us to provide while your pet is sedated

Please specify where the lumps are located *

Please specify the additional service(s) you'd like provided to your pet *

Authorization

I authorize anesthesia/sedation for my pet. The nature and risks of this procedure have been explained to me. I understand some risks always exist with anesthesia and/or sedation, 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 questions have been answered to my satisfaction. *

I have read, understand, and authorize

I authorize Monarch Veterinary Clinic to perform any additional diagnostic, treatment, or surgical procedure(s) deemed necessary for medical complications or otherwise unforseen circumstances. I understand there are rare complications associated with any anesthetic procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. I fully understand these risks and understand the veterinarians and hospital staff will try to minimize such risks. I will not hold Monarch Veterinary Clinic, the veterinarians, or any staff member liable for any complications that may arise. *

I have read, understand, and authorize

Payment is due upon services rendered. *

I have read, understand, and agree.

I HAVE READ AND FULLY UNDERSTAND THIS ANESTHESIA CONSENT FORM *

Yes

Signature of Responsible Party *

Clear Signature

Date *

By checking this box *

I agree to be contacted by Monarch Veterinary Clinic via call, email, and text. To opt out, you can reply 'stop’ at any time. For more information, see our privacy policy. Message and data rates may apply.

Anesthesia Consent Form