Sedation/Anesthesia Consent Form-Equine Medical Cente

Sedation/Anesthesia Consent Form

This form covers both standing sedation and anesthesia (if necessary). EMCO will never place a horse under general anesthesia without first contacting you/your representative for permission.

Date of Appointment

First and Last Name

Relationship to patient

Owner

Trainer

Authorized Agent/Representative

Patient's Name (Barn and Registered)

Medical/Surgical Procedure to be performed

Consent and Acknowledgement

I understand that the practice of medicine is not an exact science. No guarantees or promises can be made to me concerning the result of any procedure or treatment. I understand that, as with any medical procedure, there is always the possibility of unexpected complications associated with anesthesia. Major risks or complications associated with anesthesia include, but are not limited to, infection, excessive bleeding, drug and blood reactions, loss of sensation, loss of limb function, prolonged recumbency, paralysis, ocular dysfunction, organ damage and possibly failure, heart attack, and sometimes death. My request and consent for the procedure described above is the result of discussions with my veterinarian. I understand the risks, I have had the opportunity to ask questions, and they have been answered to my satisfaction. I acknowledge that I am the owner of the horse identified above. or an authorized agent representing the owner. I authorize and consent to anesthesia being performed upon my horse using the methods determined to be necessary by the responsible veterinarian. This includes, but is not limited to, the administration of local and epidural regional anesthetics, and intravenous and inhaled general anesthetics. I acknowledge that the name of the horse, the procedure, the limb and /or the location on the horse proposed to receive surgery is correctly identified above.

In order for the procedure to be performed at the Equine Medical Center of Ocala, it is necessary for you to sign this anesthesia consent form acknowledging that you understand that general anesthesia will be required to perform the procedure described above, that you understand the risks, complications. alternatives and benefits, and that you have authorized and consented to such procedure.

Signature

Today's Date