Avian and Exotic Animal Sedation Consent Form

Thank you for trusting East Roswell Vet Hospital, as we look forward to working with you. To save time, please fill out the Avian and Exotic Animal Sedation Consent Form below before visiting our office.

Contact our office for appointments, questions and comments: (770) 642-1282

Pet's Name*

When did your pet last eat or drink?*

Please list any known allergies or adverse reactions to anesthetics or drugs.*

Example: Vomiting, diarrhea, swelling, hives, etc.

Please list any known allergies or adverse reactions to anesthetics or drugs.*

Example: Vomiting, diarrhea, swelling, hives, etc.

Is your pet on any medication including OTC medication and supplements? If so, what is the dose, frequency and the last time the medication was given?*

Example: Vomiting, diarrhea, swelling, hives, etc.

Procedure

Would you like to add on any additional procedures?*

Yes

If you answered "yes" above, please list your desired add-on procedures below.

Consent for Anesthesia and Sedation
It is important to acknowledge that small mammals, birds, and reptiles are at a much higher anesthesia risk than other pets. While your pet is sedate we will maintain a constant record of vital signs including heart rate, respiratory rate, oxygenation levels (if able, pending on body size), blood pressure (if able, pending on body size), and temperature. This helps us to detect potential anesthetic complications early and treat them before they become life threatening.

I acknowledge that during the course of the procedure(s), unforeseen conditions may arise that could necessitate the performance of additional procedures.*

Please initial in the field above.

I acknowledge that unexpected severe complications with anesthesia can occur. In addition, risks of all anesthetics may include, but are not limited to; low blood pressure, low oxygenation leading to stroke, vomiting or regurgitation leading to aspiration and pneumonia, infection, bleeding, drug reactions, blood clots, corneal abrasions and ulcers, damage to veins, arteries or nerves, brain damage, or death.*

Please initial in the field above.

Fluid therapy (subcutaneous or intravenous) is recommended for all exotics receiving sedation or anesthesia. This therapy will be provided at an additional cost.*

DECLINE

Acknowledgements and Agreements

I have been informed that there are risks and complications associated with anesthesia and surgery. (PLEASE INITIAL)*

Please initial in the field above.

I will be available at the phone number(s) listed at all times during the day of the procedure. If the doctors and staff cannot reach me by phone, I authorize any treatment deemed necessary for the health of my pet.*

I DO

I DO NOT

I authorize treatment as deemed by the doctor over and above the treatment discussed, up to an ADDITIONAL $_________. I will only be called if such a treatment that exceeds this amount. (PLEASE LIST ADDITIONAL DOLLAR AMOUNT & INITIAL)*

Please enter a dollar amount of additional funds you are willing to spend and initial above.

If you declined the above statement, and you are requesting that we contact you prior to the performance of ANY additional treatment, you must accept the following: I fully understand that my pet will be under anesthesia longer and I accept responsibility for increased medical risk and/or cost. I also understand that if I cannot be contacted within a reasonable amount of time that my pet will be wakened from anesthesia. If I choose at a later time to have the procedure performed, it will require additional anesthesia and cost. (PLEASE INITIAL)*

Please initial in the field above.

I hereby authorize and direct the veterinarians and staff to perform the procedure(s) described above. The nature of the procedure and risks involved have been explained to me, and I realize results cannot be guaranteed. I am also aware the unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all reasonable costs incurred regarding my pet. (PLEASE INITIAL)*

Please initial in the field above.

Financial Agreement
I understand that the treatment of my pet will be conducted with due care and in accordance with the prevailing standards of competence in veterinary medicine. I certify that no guarantee or assurance has been made as to the results that may be obtained through the course of treatment undertaken by the veterinarians and staff of East Roswell Vet Hospital. I understand that a written estimate of charges is available within reasonable time of my request. In order to continue to provide the highest quality of veterinary medicine, we require payment in full at the time services are rendered. I assume financial responsibility for all charges incurred to the patient services rendered, and understand that full payment is required upon completion. I certify that I have read and understand this release, and furthermore that I assume full responsibility for all charges related to the above procedures. I am the owner (or agent for the owner of legal age) for the animal described above and I have the authority to execute this consent.

Owner's Name*

First and Last Name

Date*

Signature*

Phone Number*

ADVANCE DIRECTIVE (CPR VS DNR)

I authorize the doctor to conduct CPR without my prior consent.*

**Additional fees will accrue to perform CPR