"*" indicates required fields

Owner's Name*

SEDATION POLICIES & PROCEDURES:

Please review and initial.
I, the undersigned owner or agent of the pet identified above, hereby request and authorize the staff of Memorial Veterinary Clinic to use a sedative to treat my pet. I consent to and authorize the performance of such as necessary in the veterinarian’s professional judgment.
I understand that all patients will receive a thorough examination before sedation. Memorial Veterinary Clinic uses the safest sedative available. I understand that there are risks associated with the use of any medication. I also understand that certain risks and complications are associated with any operation or procedure of this type, including death. I acknowledge that I have had the opportunity to speak with a Memorial Veterinary Clinic licensed veterinarian about the risks and complications associated with the above-listed procedure(s).
In Case of Emergency*
I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, I agree that in the event my pet experiences a cardiac, respiratory, or other life-threatening emergency that requires resuscitative or other urgent care measures, such as cardiopulmonary resuscitation (CPR), positive pressure ventilation, emergency drugs, or other similar measures, I request that the veterinarians and/or trained staff at Memorial Veterinary Clinic pursue such medical care as indicated below. (client required to select one)
If my pet injures itself in an escape attempt, refuses food, soils itself, becomes ill, or passes away at the hospital, I will hold Memorial Veterinary Clinic and staff free of all responsibility and/or liability in the absence of gross negligence.

Authorization

I hereby certify that I have read and fully understand this authorization for sedating my pet at Memorial Veterinary Clinic. I assume financial responsibility for all charges incurred to the above pet(s) and agree to pay all such charges after this stay.

MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.