Proceedure Release Consent Form Name* First Last Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Pet's name*Species*Breed*Color*Age*Sex*Weight*MicrochipConsent SectionI am the owner of the above described animal and have the authority to execute this consent and authorization for the following procedures / care. Anesthesia / Sedation: Anesthetic episodes carry an inherent risk. Undoubtedly the importance of the procedure outweighs the potential for complications. There are certain measures, detailed below, that are taken to minimize the risks during anesthesia and surgery. I understand that during the performance of this procedure, unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s). I expect Blue Ridge Veterinary Associates to use reasonable care and judgments in performing the procedure(s). The nature of the procedure and risks have been explained to me and I realize results cannot be guaranteed. I am also aware that unforeseen events (including death) resulting from the procedure(s) will not relieve me from my obligation to all reasonable costs incurred regarding the animal.Pre-Anesthetic Bloodwork*By testing blood chemistries and hematology values, we can better evaluate the status of your pet’s major organ systems. This is important because certain organs process and rid the body of medications used during anesthesia. The numbers of certain blood cells can determine how well oxygen is delivered to the body’s organs, how well the body can fight infection, and how well blood is able to clot during and after surgery. These functions are often altered with age and certain disease states. (Highly recommended). I authorize Pre-Anesthetic Bloodwork: Yes No Name:*Date:*IV Catheter IV*Catheters are recommended during any procedure when a pet is undergoing anesthesia. It is used to obtain open vein access for delivery of drugs, medications and fluids. I authorize IV Catheter Yes No Name:*Date:*Dentistry*Dentistry consists of an oral examination with sedation, scaling and polishing the teeth. Often times extractions are necessary to eliminate bad teeth. Healthy teeth and gums promote overall health to pets. I authorize Dentistry Procedure/treatment. Yes No Name:*Date:*Name:*I authorize necessary extractions:Date:*Radiographs*Anesthesia / Sedation, if required. I authorize this procedure.. Yes No Name:*Date:*Hospitalization*I certify that I am the owner/agent (or person responsible) for the animal described above. I authorize the procedures indicated above with my signature as well as those procedures provided to me in a written or verbal estimate of care. I give the doctors and their assistants complete authority to treat this animal in whatever manner they recommend. In the event the staff is unable to contact me for further authorization, I give authorization by signature listed below for any treatment deemed necessary by the veterinarian on duty. Yes No Name:*Date:*NotificationPlease list any/all veterinary facilities you would like us to notify of your visit and the status of your pet.