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Anesthetic Release Form

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Day of Sedation *

Owner Name

Your First Name: *

Your Last Name: *

Phone: *

This must be the best number to reach you at regarding your cat.

Email: *

Which would you prefer for updates and communications about your cat? *CallTextEmail

Procedure to be Performed *

Did you keep your cat off food and water for at least 12 hours? *YesNo

Is your cat on any medications? *YesNo

If yes, please explain:

When was flea and tick prevention last given and what type? *

Our kennel has a “NO FLEAS AND TICKS” policy. If your cat is examined and found to have fleas or ticks, they will be treated at an additional cost.

Has your cat seemed healthy to you? *YesNo

If no, please explain:

While your cat is sedated, would you like us to perform any of the following procedures at an additional cost?Home Again Microchip Placement ($55.90 )Pedicure (No Charge)Shave rear ($13.00 and up, plus tax)Shave matts ($15.00 and up, plus tax)

Owner’s Birth Date *

State laws and regulations have changed and now require practices to provide owner birth dates to report controlled substances.

List person, other than you, authorized to pick up your cat:

First Name:

Last Name:

Phone:

Today’s Date: *

Owner Signature: *

Please do not fill in this field.

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3100 N. College Ave.
Fayetteville, AR 72703
Phone: 479-571-1228

Monday: 7:30am-5:30pm
Tuesday: Closed
(alternates with Saturdays)
Wednesday: 7:30am-5:30pm
Thursday: 7:30am-5:00pm
Friday: 7:30am-5:30pm
Saturday: 7:30am-12:00pm
(alternates with Tuesdays)
Sunday: Closed

Emergency Clinic: Animal Emergency
and Specialty Clinic of NWA
881 Metroplex Dr.
Springdale, AR 72762
479-927-0007

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