Client Forms Lane Veterinary

Dropoff & Sedation Consent Form

Dropoff & Sedation Consent Treatment Form
Please fill out this form in entirety to ensure we can provide your pet with the best possible care.
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
It is imperative that we be able to reach you in a timely manner while your pet is in the building today. Please have your cell phone listed above available and be free to talk.
Is there anyone else we can call regarding your pet while they are here today?

Alternative Contact Information

Contact's Name
Contact's Name
First
Last

Pet Information & History

Please list type of visit: ultrasound, lab work, drop off appointment, etc.
i.e. daycare, groomers, vacation home, etc.
Has your pet had any food since midnight last night?
Has your pet been vomiting or having diarrhea?
Does your pet have any allergies?
Has your pet ever had any adverse reaction to medication?
Has your pet ever had an adverse reaction to vaccines?
Has your pet ever had an adverse reaction to anesthesia?
Does your pet take heartworm, flea, and tick medication?
Is Your Pet Current On Vaccinations?
My pet's vaccines were administered last by
Would you like your pet microchipped today?
Do you have pet insurance?
If yes, please tell us more. If no, please note N/A.

Authorizations

I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize treatment of my pet to be performed by Lane Veterinary.
I have been advised as to the nature of this procedure to be performed and the risks involved. No guarantees have been made regarding the outcome or cure. I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure. This risk includes serious bodily injury or death. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any result in additional charges.
I agree to be responsible for all charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24 hour hospital).
In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference
I acknowledge my choice regarding resuscitation choice for my pet as noted above.