"*" indicates required fields Owner's Name* First Last Pet's Name* TODAY’S CONTACT NUMBER(S): (Primary)*Alternate NumberSEDATION POLICIES & PROCEDURES:Please review and initial.Consent*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. Examination*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) Resuscitate (R): I authorize emergency treatment if the situation arises (including cardiopulmonary resuscitation (CPR) and other life-saving treatments) and understand this may result in additional charges. I agree to pay for these emergency and life- stabilizing treatments even if they exceed any estimate I may have been provided. Do Not Resuscitate (DNR): I do NOT authorize emergency treatment if the situation arises (including cardiopulmonary resuscitation (CPR) and other life-saving treatments) and prefer to be contacted before any additional treatment is performed. Liability Release*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. Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.