Anesthesia Release Form - Agape Mobile Veterinary Care

Owner's Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Contact Information

Day-Time Phone*

Evening Phone

Mobile Phone

Email*

Confirm Email*

Pet Information

Pet's Name

Species*

If other species not listed above

Breed (If known)

Color

Weight

Microchip Number (if applicable)

Date of Birth (if known)

Special Identification (tatoo, microchip, etc.)

Sex

Date of Procedure

Date

Name of Veterinarian

First Last

Description of Procedure

Anesthesia Details

I, the undersigned owner or authorized agent of the above-named pet, hereby authorize Agape Mobile Veterinary Care to administer anesthesia to my pet for the specified procedure. I understand and agree to the following:

Anesthesia is Generally Safe: I understand that anesthesia is generally safe, but all medical procedures carry some level of risk.
Anesthetic Risks: I am aware that, despite all safety precautions taken by Agape Mobile Veterinary Care, there are inherent risks associated with anesthesia, including but not limited to allergic reactions, adverse reactions to medications, and unforeseen complications.
Monitoring: I understand that my pet will be continuously monitored during anesthesia, including heart rate, respiratory rate, blood pressure, and oxygen levels, to ensure their safety.
Emergency Procedures: I authorize Agape Mobile Veterinary Care to take any necessary emergency measures to ensure the safety and well-being of my pet during the procedure, including but not limited to administering additional medications, performing CPR, or other life-saving measures.
Communication: I acknowledge that Agape Mobile Veterinary Care will make every effort to contact me during the procedure if any unforeseen complications arise. In the event that they cannot reach me, I authorize them to use their best judgment in the best interest of my pet.
Cost Estimates: I have been provided with a cost estimate for the procedure, including anesthesia and any additional services that may be required. I understand that charges may vary based on the actual care provided.
Financial Responsibility: I agree to pay all charges associated with the procedure, including anesthesia, and any additional services required.

Consent and Agreement

I have read and understand the information provided above regarding the administration of anesthesia to my pet. I consent to the use of anesthesia for the specified procedure and agree to the associated risks and costs. I understand that Agape Mobile Veterinary Care will make every effort to ensure the safety of my pet during anesthesia but cannot guarantee outcomes.

Signature

Date