Pharmacy Emergency Services

Avian and Exotic Animal Sedation Consent Form

Welcome! Prior to your pets upcoming procedure, please fill out the form below.

Step 1 of 3

Client's Name *

First

Last

Pet's Name *

Phone Number *

Please provide the number where you can be reached during the procedure.

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.

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 procedures? *

Yes
No

If Yes, Please describe in the field below.

List any add-on procedures:

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. *

ACCEPT
DECLINE

Acknowledgments and Aggreements

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

Please initial in the field above.

I release East Roswell Vet Hospital and staff from any liability relating to unforeseen complications arising from surgery and/or anesthesia. (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 in the field 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.

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Accessibility by WAH

Address: 1570 Holcomb Bridge Road, Suite 110
Roswell, GA, 30076

Email: [email protected]

Phone: (770) 642-1282

Fax: (770) 769-2956

Text: (678) 263-7762

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