Anesthetic Release Form

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:

Recommended for ALL ages, especially senior cats (10 years +). We recommend performing a pre-surgical screening (lab tests to evaluate the liver and kidneys) BEFORE using any anesthetic (unless these test were done in the last 30 days). These tests allow us to see “inside” your cat and make informed decisions about the best way to treat him/her medically

Do we have permission for these OPTIONAL tests? Cost is ~$124.00 *YesNo

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: *

!Side Menu Images

!Mobile Content

!Header Logo

!Give us a call button

!Call Icon