Sedated Procedure Release Form

I hereby entrust Oswego Veterinary Hospital (OVH) to care for my pet during his/her surgery stay. I am the owner, or a representative of the owner, of the animal presented and have the authority to execute this consent. I understand the doctors and staff will use all reasonable precaution against the injury and/or death of my pet, and I hereby consent and authorize this hospital to perform the requested anesthesia and surgical procedures.
Our surgery team takes every precaution to ensure the safety of your pet, and while complications from anesthesia and/or surgery are rare, they are not impossible. I understand that potential complications include but are not limited to death, blindness, dehiscence or infection of incisions, or progression of underlying heart, kidney, or liver disease.

In the event of unforeseen complications, I give permission to the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action. I understand that I must furnish phone number(s) where OVH can reach me or a contact person whom I have authorized to make medical decisions. I have been advised as to the nature of the procedure to be performed and the risks involved. I understand the nature of today’s procedure based on the treatment plan provided previously by OVH and conversations with the doctor and/or surgical staff. *

I have read and understand.

Patient Name *

Name of contact person *

First

Last

This person is: *

Owner
Authorized Agent

Procedures requiring anesthesia or sedation are time-sensitive and provide a narrow window of time in which to reach you. For your pet's safety, please list where you or your agent can be reached without delay. We will use this phone number for all requested communications unless otherwise specified. Please provide a phone number below. *

I have read and understand.

Phone *

In the event you or your authorized contact person are not reachable, would you prefer us to proceed with any additional recommended treatment? Please select your preference: *

Yes, please proceed with additional treatment. I understand that there will be additional charges for further treatments.
No, please do not proceed with any treatment beyond the initial treatment plan, unless my pet's safety requires it.

Email *

Telephone is our primary means of contacting you regarding your pet's procedure, however we sometimes email updated estimates, forms, home care instructions, etc.

Would you like to be notified when your pet is about to undergo their procedure? *

Yes, via text
Yes, via a phone call
No, I do not need to be notified when my pet is about to be anesthetized.

Please list phone number to text if different than above:

Please list phone number to call if different than above:

Would you like to be notified when your pet wakes up from sedation/anesthesia? *

Yes, via text
Yes, via a phone call
No, I do not need to be notified when my pet wakes up

Please list phone number to text if different than above:

Please list phone number to call if different than above:

I understand that the safety of my pet is the overriding priority. I understand that any price quote I have been given is an estimate and if complications are involved, or the procedure is of greater dimensions than anticipated, the price may be higher. I understand that by signing below, I agree to pay for all charges incurred as such and will pay the balance in full upon discharge of my pet. *

I have read and understand.

Signature *

Printed Name *

First

Last

Today's Date *

PRE-PROCEDURE QUESTIONNAIRE

Please complete no later than 4pm on the day prior to your pet’s procedure.

I agree to feed no more than ¼ of my pet’s regular meal on the morning of the procedure OR will fast my pet for 12 hours if being seen for an abdominal ultrasound: *

Yes
No - if selected, please contact us immediately at 503-636-3001

Is your pet on any medications? *

Yes
No

If yes, please list the name of medication(s) and when the last dose was given. If you have questions as to whether your pet should receive medications on the morning of surgery, please call us at 503-636-3001. *

Has your pet been ill recently? *

Yes
No

If so, please describe the symptoms and indicate date/time of last symptoms: *

Would you like your pet to have a nail trim while sedated? *

Yes
No

Do you need any medications refilled? *

Yes
No

If yes, please list the medication you need refilled. *

Do you have any other questions or concerns for the doctor?

Are there any additional services you would like us to perform while your pet is in the hospital (charges may apply)?

Is your pet on a prescription or special diet? *

Yes - If yes, please bring some of their own food with you to check in.
No

I understand that all accounts are payable at the time of discharge unless a prior arrangement has been made.

I have read and understand.

Signature *

Date: *

Complete your form online!

PRE-PROCEDURE QUESTIONNAIRE