"*" indicates required fields Owner's Name* First Last Phone*Email* Emergency Contact Name Emergency Contact PhonePet's Name* 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 for the treatment of my pet. I consent to and authorize the performance of such as necessary in the veterinarian’s professional judgment.* I have read and agreeI understand that all patients receive a brief examination before sedation. Memorial Veterinary Clinic uses the safest anesthesia available. I understand that there are risks associated with the use of any medication. I also understand that there are certain risks and complications 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).* I have read and agreeI 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 experience 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.* Resuscitate (R): I authorize emergency treatment if the situation arises (including cardio pulmonary resuscitation (CPR) and other life-saving treatments) and understand this may result in additional charges and 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 cardio pulmonary resuscitation (CPR) and other life-saving treatments) and prefer to be contacted before any additional treatment is performed If my pet injures itself in an escape attempt, refuses food, soils itself, becomes ill, or passes away while in the hospital, I will hold Memorial Veterinary Clinic and staff free of all responsibility and/or liability in the absence of gross negligence.* I have read and agreeI hereby certify that I have read and fully understand this authorization for sedating my pet at Memorial Veterinary Clinic, and I assume financial responsibility for all charges incurred to the above pet(s) and agree to pay all such charges at the completion of this stay.Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
