8:30 AM – 5:00 PM
Sat & Sun:
6630 NE 181st St. Suite F103,
Kenmore, WA 98028-4852
Anesthetic Release Form
Anesthetic and surgical procedure(s) to be performed:
I, the undersigned owner or agent of the pet identified above, authorize the staff of Kenmore Veterinary Hospital to perform the above procedure(s). I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the attending veterinarian will perform appropriate life saving measures unless you decline such measures:
I give permission for life sustaining procedures – CPR (Cardiopulmonary Resuscitation)
I do not give permission for life sustaining procedures – DNR (Do Not Resuscitate)
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. A pre-anesthetic exam will be performed on your pet prior to the surgical procedure. Pre-anesthetic blood work is recommended for all pets and required for pets over 7 years of age. I have read and fully understand the terms and conditions set forth above. I am the owner (or agent for the owner) of the above described animal, am over the age of 18 years old and have the authority to execute this consent. Notice regarding overnight hospitalization At Kenmore Veterinary Hospitall, between the hours of 7pm and 7am there is no staff present to monitor or treat patients. We sometimes keep stable post-surgical and medicine cases overnight at Kenmore Veterinary Hospital. If the veterinarian managing the case feels that it is in the patient's best interest to be monitored overnight, you will be advised prior to 7pm and asked to transfer your pet to a facility for overnight care. We currently recommend BluePearl Specialty + Emergency Pet Hospital in Tacoma. They can be reached at (253) 474-0791. If you have any questions regarding our policy, please do not hesitate to ask.
I have read and understand this authorization and consent. I take full responsibility for payment at the time of service.
Phone number(s) you can be reached at today or tomorrow:
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