Anesthesia Authorization Release Form Please fill out the following for the upcoming scheduled surgery. Rescue Group Name * Name of person bringing in pet * First Name Last Name Pet Name * Procedure Being Performed * Preanesthetic Bloodwork: These tests may reveal underlying disease of liver, kidney, or blood, which can increase risk of anesthetic complications. *I understand that if the doctors feel there is unacceptable risk, based on my pet's physical condition or laboratory test results, they may elect to cancel the requested procedure(s). * I authorize preanesthetic testing as previously recommended by the doctor. Testing has already been done in preparation for today's procedure(s). (Within 6 months) I do not authorize preanesthetic testing. I accept full responsibility for any adverse complications that may arise as a result of my decision to anesthetize without the benefit of preanesthetic testing and the information it provides IV (or SQ) Fluid Therapy: Intravenous fluid therapy (and subcutaneous fluid therapy for feline neuters) helps to maintain stable blood pressure during anesthesia and protect blood flow to the vital organs. Fluid therapy also helps in the elimination of anesthetic drugs after anesthesia is complete. It is strongly recommended for all patients undergoing anesthesia, and required for patients with liver or kidney disease. * I authorize IV (or SQ) fluid therapy during anesthesia to be administered as the doctor deems advisable. I do not authorize IV (or SQ) fluid therapy during anesthesia. I understand that alterations in blood pressure during anesthesia may cause injury to vital organs and I accept full responsibility for any adverse complications that may arise. Dental Extractions: I understand that dental cleaning may reveal diseased or damaged teeth that require extraction. I also understand that young pets may have retained deciduous teeth that will need to be extracted to prevent the adult teeth from becoming diseased or damaged. I request that the doctor do the following: * I understand that if the doctor is unable to reach me in a timely fashion, no additional teeth will be extracted at this time and that extraction at a later date will require repeat anesthesia and will therefore add substantially to the overall cost of dental surgery. Extract NO TEETH unless I can be reached at the phone number below for authorization. Extract all diseased, damaged, or retained deciduous teeth as the doctor deems appropriate. I agree to pay for extraction costs in the event I cannot be reached at the phone number below. Not Applicable Tattoo: (Spays/Neuters) I understand that my pet will have a green tattoo mark placed on the surface of its skin to designate that he/she has been spayed/neutered. These tattoos tell future veterinary professionals that yes, the animal has been sterilized, since scars can fade over time, and future situations may call for your pet to be with new owners. This tattoo is a 1 cm long green line that will be beside the spay/neuter incision. There is NO FEE for this tattoo. * I authorize tattooing my pet. I do not authorize tattooing my pet. My pet is not getting spayed or neutered; this does not apply. If fleas are found on my pet, an Advantus/Capstar tablet will be administered at my expense. * I understand. For all patients being admitted: In the unlikely event of your pet experiencing an unexpected cardiac or respiratory arrest while in our care, please indicate one of the following: * I WANT the medical staff at Davis Animal Hospital to attempt to resuscitate my pet. *By signing this line, I am also indicating that I understand that survival rate is less than 10% and that I am responsible for any additional cost associated with the attempt to resuscitate my pet. I DO NOT want the medical staff at Davis Animal Hospital to attempt to resuscitate my pet. I am the owner/authorized agent for the animal named above. I give permission for the procedure(s) named above. I understand that the doctors and staff of Davis Animal Hospital will use all reasonable precautions against injury, escape, or death of my pet. I understand that anesthesia and surgery always involve some risk to my pet (such as unknown internal physical abnormalities, medication allergies, surgical complications, internal bleeding, shock, incision dehiscence, and post-surgical infections) and agree to hold the hospital and its employees harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event complications arise and I cannot be immediately contacted at the below listed phone number(s), I request that the doctors and staff make the medical decision deemed best for my pet. * I have read the foregoing, understand what it says, and agree. E-Signature * Typing my initials confirms that the above information is accurate to the best of my knowledge. * Phone number of the person who will be bringing and picking up pet the day of surgery. * (###) ### #### Thank you!
