Non-Sedated Release Form The following information is necessary in order that we might serve you better and give you the personal attention your pet deserves. Please fill out the form completely.Owner's Name* First Last Pet's Name*Phone*We MUST have a phone number of someone that can be reached while your pet is in the hospital.Please provide a brief history of the reason for visit*If your pet is presented to the hospital with fleas, we will give is a safe flea medication to eliminate the fleas. The cost of this service is $10.00 (INITIAL)*Some animals can become frightened or aggressive while in an unknown environment, making it difficult to examine. If this case I give my consent for the Doctor(s) to use necessary sedation for my animal. I understand that if this is the case there will be a fee. I realize that there is a risk (although small) involved with any type of sedation and those risks have been explained to my satisfaction. (INITIAL)*We try our best to provide you with an accurate estimate of charges, however there are times that we must alter the initial estimate that you were given. In that event we will call you to discuss charges with you. (INITIAL)*A pre-payment equal to the estimated amount is required. Should the payment exceed the final bill, the balance will be refunded or credited to your account. (INITIAL)*Resuscitation OrderPlease read the following carefully and initial next to procedures you wish to be performed in the case of an emergency.In the event of cardiac or respiratory arrest I authorize the responsible veterinarian to resuscitate my pet by performing one or more of the following procedures*YES to resuscitationNO to resuscitation. I consent in the event of cardiac or respiratory arrest that NO attempts to resuscitate my pet be performed.)Type of resuscitationExternal Cardiac Massage (CCPR) Cost range $ I 00-$400.Internal Cardiac Massage Cost Range $1000-$2000Post-resuscitation procedure care most likely will include overnight monitoring at a 24-hour emergency facility at additional cost to the pet owner.Signature of Owner/ Agent*Date* NameThis field is for validation purposes and should be left unchanged.