Sedation or Anesthesia & Surgery

I, the undersigned, being 18 years of age or older, am the owner or agent of the animal described above and am authorized to make decisions regarding its care.  I hereby acknowledge that the Animal Medical Center of Mid-America veterinarian(s) have advised me of:

  • The diagnosis of my animal's medical condition, if applicable.
  • The general nature of the proposed treatment/procedure(s).
  • The expected benefits of the proposed treatment/procedure(s).
  • The material risks or dangers and side effects of the proposed treatment procedure(s), which may include:
    • Infection, which may require additional testing and medication at an additional cost
    • Hemorrhage or bruising
    • Swelling or edema post-operatively
    • Unforeseen reaction to anesthesia
    • if applicable) implant breakage or failure, requiring additional surgery at an additional cost
  • Reasonable alternative courses of action available and risks/benefits of each. I realize that results cannot be guaranteed.
  • Consequences if the treatment/procedure is not performed.
  • Anticipated cost of the treatment/procedure (which I agree to pay at the time of discharge) as detailed on an itemized estimate of charges. I understand that the listed charges are estimates, and actual charges may be increased due to unexpected circumstances or complications which may arise.
  • I authorize the appropriate anesthetics, and other medication, and understand that unforeseen complications may arise as result of anesthesia being administered, I understand that hospital support personnel will be employed as deemed necessary by the veterinarian.
  • I understand that all reasonable precautions will be taken against injury or escape of the animal, but the Animal Medical Center of Mid-America or its agents will not be liable or responsible to any person under any circumstances for or on account of the care, necessary surgical procedures/treatment or safe keeping of the animal, and I assume all risk with respect to the treatment and care of the animal.
  • I understand that during the performance of the foregoing procedure(s) or operations, unforeseen conditions may be revealed that necessitate an extension of the foregoing procedures or operations or different procedures or operations than those set forth above. Therefore, I hereby consent and authorize the performance of such procedures or operations as is necessary and desirable in the exercise of the veterinarian's professional judgment, including the performance of CPR.
  • I understand the animal must be picked up by close of business today unless directed otherwise by the veterinarian, and that if the animal is not picked up on the specified date, the Animal Center of Mid-America will try to contact me, but I agree that:
  • If I do not pick up the animal on the specified date, and the veterinarian determines that the animal requires overnight emergency medical treatment, I authorize the Animal Center of Mid-America to transfer the animal to the Animal Emergency Clinic (or to another 24 hour emergency facility chosen by the veterinarian) for such medical treatment, and I agree that I am responsible for all costs associated with transport to such emergency facility as well as all costs for any care provided to the animal while under the emergency facility's care/supervision.
  • If I do not pick up the animal on the specified date, and the animal does not require overnight emergency medical treatment, or I do not pick up the animal at the completion of any emergency medical treatment, I understand and agree that:
    • The animal will be held by the Humane Society of Missouri in its shelter facilities without overnight medical supervision; and
    • I release the Humane Society of Missouri of any responsibility for injury or illness that may arise from my animal being present in the shelter facilities; and
    • The Humane Society of Missouri may provide care to stabilize my animal's condition and/or to relieve and reduce suffering by my animal, but  shall not be responsible for providing any additional diagnosis, medical treatment, and/or surgery beyond this level of veterinary service; and
    • I will be responsible for all additional costs incurred in holding and any additional treatment provided to my animal; and
    • The ownership of my animal may be relinquished to the Humane Society of Missouri, and the Humane Society of Missouri may determine the disposition of the animal, including adoption or euthanasia, in the sole discretion of the Humane Society of Missouri.
  • I hereby relieve the Humane Society of Missouri and its agents from all legal responsibilities in the event that I fail to pick up my animal on the specified date.
By typing your name here and submitting you agree to the terms above.