ANIMAL HOSPITAL OF SAN ANTONIO
2210 NW LOOP 410
SAN ANTONIO, TEXAS 78230
210 344-0501 fax
SEDATION/ANESTHESIA/SURGERY RELEASE FORM
CLIENT NAME _________________________________________________________________________
PATIENT NAME ________________________________________________________________________
ADDITIONAL INSTRUCTIONS _____________________________________________________________
TELEPHONE NUMBERS FOR TODAY______________________________________________________
I hereby give my permission to the Doctor(s) and Staff of the Animal Hospital of San Antonio to perform the above procedure(s). I understand that sedation and/or anesthesia will be necessary in order to perform the(se) procedures(s). I understand that any time sedation, anesthesia, or the above listed medical procedure(s) are performed there is some risk to my pet. I realize that no guarantee can ethically be made regarding the results of the(se) procedure(s). I understand that I assume financial responsibility for all services rendered and that payment is due on the date of the surgery.
Medication for surgically related pain is not an option.
YES _____ I give my permission to make any necessary change(s) to the(s) procedure(s)
YES _____ I wish to be notified before any changes are made in the above procedure(s).
YES _____ I agree to the following additional procedure(s):
_____ Pre-anesthetic blood profile (recommended for all patients)
_____ Geriatric blood profile (recommended for all patients over 8 years old)
_____ Pre-anesthetic ECG (cardiac patients)
_____ Pre-anesthetic radiographs
_____ ECG monitoring during procedure.
I understand that the above are additional laboratory services and are not included in the cost of the basic procedure.
OWNER'S SIGNATURE DATE
AGENT’S SIGNATURE DATE