Authorization for Anesthesia The following information is necessary in order that we might serve you better and give you more personal attention. Please fill out the form completely.Name (owner)(Required) First Last Phone number where I can be reached today(Required)Pet's name(Required) What procedure is your pet coming in for?(Required) Mark that which applies to you.Pre-Anesthetic Blood Work(Required)I understand that anesthesia carries a risk (though small). Therefore, blood testing is recommended before general anesthesia. The anesthetic agent is removed from the body by the liver and kidneys. Blood testing helps us evaluate these organs and is strongly recommended in all pets, especially those over 6 years of age. $75.00 | Comprehensive Chemistry Screening with PCV - Designed to provide a complete diagnostic chemistry analysis for pre-anesthetic testing, general health profile, geriatric testing and wellness testing. $48.00 | Pre-anesthetic Panel - Used to determine kidney and liver function prior to anesthesia. I Decline - I do not wish to receive any pre-anesthesic blood tests for my pet. Intraveneous (IV) Catheter and Fluid Support(Required)Administration of IV fluids during anesthesia helps maintain blood flow to the organs and keeps blood pressure normal. This increases the safety of anesthesia. Having an IV catheter in place also gives fast intraveneous access in case of emergency. Your veterinarian may require IV fluids during certain procedures. $55.00 | Placement of IV catheter and administration of fluids during procedure. I Decline catheter placement and fluid support. Additional Services While Under Anesthesia Vaccinations E-Collar | $5-$12 FIV/Leukemia Test (cats only) | $38.00 Nail Trim | Free Microchip | $35.00 Express Anal Glands | $10.00 Clean/Pluck Ears | $10.00 Heartworm Test | $20.00 Which vaccines does your pet need? Rabies DAPP/DHPP Leptospirosis Bordetella Canine Influenza Rattlesnake FVRCP FeLV Has your pet ever been under any type of anesthesia before?(Required) Yes No I Don't Know If yes, are you aware of any complications?Medication Preference (when possible) Pills Oral Liquid Injectable Is your pet having a dental procedure today? Yes No Tooth Extractions | Do you authorize all medically necessary extractions to be performed?(Required)It can be difficult to predict if teeth need extraction when an animal is awake because tartar and movement can interfere with the assessment. Diseased teeth can cause considerable pain and discomfort and act as a source of infection for other organ systems (kidney, liver, lungs and heart). During the dental cleaning, the teeth are evaluated, and if found to be diseased, they may require extraction. The cost of extractions vary and an estimate of these costs would have been accounted for in your dental estimate. Yes No Dental Radiology | $130 for dogs and $95 for cats.(Required)Dental radiology is fast becoming the standard of care in veterinary dentistry. Full mouth dental radiographs are recommended for every patient undergoing a dental procedure in order to better evaluate your pet’s oral health. Much of the teeth lie below the gum line and most dental disease occurs below the gum line. Radiographs aid the doctor in determining the health and structure of the teeth. In a majority of cases, radiographs can confirm the necessity for extraction of a tooth that is loose, damaged or otherwise diseased. It also allows for post-extraction x-rays to be taken to ensure the entire root was extracted. I authorize dental x-rays to be performed at the additional fee. I decline dental x-rays at this time. I agree to the following:(Required) The nature of such a service has been described to me to my satisfaction and I realize that no guarantee, nor warranty can ethically or professionally be made regarding the results or cure. I Agree to the following(Required) I understand and assume financial responsibility for all services rendered. I understand that payment is due when my pet is released from the hospital. All animals undergoing a spay or neuter surgery will receive a small, green tattoo to indicate that the animal has been sterilized.Type your full first and last name to sign this form.(Required) Date MM slash DD slash YYYY
