Sedation Consent Form

By completing and submitting this form, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By submitting this form using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement.

Name*
First Last
Email*
Best Phone number to call you at today:*
Pet's Name*
Procedure(s) to be performed:*
Surgical Authorization*
I, the undersigned owner (or agent of the owner) of the pet identified above, certify that I am/am not (selected below) eighteen years of age or older and authorize the veterinarians at MILLS VETERINARY SERVICES to perform the above procedure(s).

I understand that some risks always exist with sedation and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is initiated. While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I certify that no guarantee or warranty has been made regarding the results that may be achieved.

I acknowledge that the entire fee is payable when the service is performed. Should unexpected lifesaving emergency care be required and the hospital's staff is unable to reach me, the staff has/does not have (selected below) my permission to provide such treatment and I agree to pay for such services.
Read & Acknowledged
Age of undersigned owner (or agent of the owner)*
- 18 years of age or older
- Under 18
Emergency Services*
Should unexpected lifesaving emergency care be required and the hospital's staff is unable to reach me, the staff has/does not have (select one) my permission to provide such treatment and I agree to pay for such services.
- Yes
- No
If your pet has been under anesthesia in the past, has it ever had any anesthetic difficulties?*
- Yes
- No
Yes / No - If yes, please describe the difficulties and drugs used if known.*
What, if any, medication is your pet taking?
Time of last dose?
If sedated, would you like your pet’s nails trimmed today while they are sedated? (no charge)*
- Yes
- No
Electronic Signature Disclosure and Consent*
By typing my name and submitting this form, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By submitting this form using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement.
Signature Date*
Date Format: MM slash DD slash YYYY

Location

4285 MacDonald Road,
Spallumcheen (Armstrong), BC,
V4Y 0N2

Contact

Phone: 250-546-8860
Email: office@millsvet.com
Fax: 250-546–8867

Hours

Monday – Friday: 8:00am – 4:00pm
Saturday & Sunday: Closed
Closed for STAT Holidays

Please note that we are located outside of Armstrong, in a rural area. Using a GPS or Map App will provide the best directions.