Permission for Sedation

Prior to certain procedures sedation may be necessary for your pet’s safety.
Please read carefully and complete before your pet’s scheduled date of treatment.

For a Surgical Procedure

The following agreement is made between Howard Beach Animal Clinic and the person named below who is the owner of the above described animal or the agent of the owner.
2. I consent to, and authorize, the performance of
a. General anesthesia of my animal
b. Sedation of my animal
3. My animal has been fasted
4. I understand that risks and potential complications exist with anesthesia/sedation, treatments and procedures. These may include, but are not limited to abnormal reaction to anesthetic agents, organ failure (heart, liver, kidney), obstructed airway, regurgitation, aspiration pneumonia, gastric dilationvolvulus (GDV), nerve damage, surgical site breakdown, infection, failure of procedure/treatment, failure to heal/improve, worsening of condition, recurrence of condition and death.
5. In the event of cardiac arrest, I desire Cardiopulmonary Resuscitation (CPR) measure to be performed on my animal.
6. If dental procedure is undertaking - I understand that every attempt will be made to contact me the owner/ Agent prior to extractions; however if HBAC is not able to get into contact with me I consent to having the veterinarian overseeing my animal’s procedure to make the decision on what is best for my animal.
7. The owner/agent hereby agree that treatment recommendations, success rate, and possible complications have been explained to him/her and that successful outcome cannot be guaranteed.
8. I understand that surgically removed tissues will be processed according to hospital policy, to establish an accurate diagnosis.
9. I understand that HBAC operates on a payment-at-time-of-service basis for all outpatient (routine, specialty and emergency) office visits, procedures, prescriptions and lab services.
10. I understand that owners/Agents of hospitalized animals are required (on admission) to make a payment equal to 50% of the high-end estimate range. Revised estimates may require additional payments.
10. I understand that owners/Agents of hospitalized animals are required (on admission) to make a payment equal to 50% of the high-end estimate range. Revised estimates may require additional payments.
12. I understand that this is only an estimate and the final billing may vary according to the needs of my animal as the case proceeds. It is impossible to precisely estimate the cost of medical or surgical treatment. Thus, this estimate is not a guarantee of the final charges, which may be more or less than the estimated amount, dependent upon the extent of treatment required. I also understand that should charges exceed this expected estimate by more than 10%, an attempt will be made to contact me at the time to discuss your animal’s further diagnostic and/or treatment requirements and to ascertain whether I wish to proceed further.
This estimate is not a firm quote and as such is subject to change due to unforeseen circumstances. Due to the complex nature of most cases we see, the final charges may vary from this estimate. We will make every effort to inform you should your pet’s changing condition require substantial procedures or diagnostic work not outlined in the above estimate. As part of our ongoing commitment to your pet’s health, we encourage you to call if you have any questions. Please call the hospital at 718.848.6803.
I certify that I have read and fully understand this authorization, accept the terms and estimated costs. I hereby release Howard Beach Animal Clinic staff from any and all claims, except claims of negligence, arising out of or connected with the medical care of the above-described animal.
I am the owner of the above-described animal or the agent of the owner; I am over 18 years of age, and have the authority to complete this consent form.
MM slash DD slash YYYY