Spay/Neuter Anesthetic Procedure Authorization

Client Name*

Pets Name*

Procedure(s) to be performed*

Primary Contact Number*

Secondary Contact Number

Would you like to have pre-anesthetic blood tests performed today for a cost of $87?

Yes
No
Already Performed

Blood Testing For Pets Under 6 years old: Pre-anesthetic blood tests help ensure your pet’s liver and kidneys are working well, and ensure they have the appropriate levels of red blood cells, blood proteins, and blood sugar. Each of these things are important while under anesthesia. It is uncommon or younger pets to have issues with these parameters, but pre-anesthetic blood testing is the only way to be certain. Changes on blood tests are more common in older pets, so pets over 6 years old are required to have pre-anesthetic blood tests.

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am of eighteen years of age or over and authorize the veterinarian(s) at this practice to perform the above procedure(s). I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:

The reasonable medical and/or surgical treatment options for my pet
Sufficient details of the procedures to understand what will be performed
How fully my pet will recover and how long it will take
The most common and serious complications
The length and type of follow-up care and home restraint required
The estimate of the fees for all services
Any necessary payment arrangements

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that veterinary medicine is not an exact science and that no guarantee or warranty has been made regarding the results that may be achieved. I agree to pay the estimated fees, assume financial responsibility for the remaining fees, and provide payment in full at the time my pet is discharged from the hospital. Should an unexpected critical situation arise (choose one):

*

I authorize and accept financial responsibility for the veterinarian(s) and staff to perform lifesaving procedures.
I choose that the veterinarian(s) and staff DO NOT resuscitate my pet.

Did your pet take medications in the last 24 hours?

Yes
No

Medication

Strength

Time Given

I have read and understand the nature of the above procedures and give my consent to proceed.

Microchipping

Microchipping is the most permanent Pet Identification system available today. Often the best time to place a microchip is when the pet is under anesthesia so the pet does not have to feel the pain of the larger than average needle.

Would you like to have your pet microchipped during this procedure?*

Yes
No

I understand that fees beyond the estimate for this procedure may result if it is found that my pet is in heat or cryptorchid.

Occasionally while under anesthesia deciduous teeth are found in pets that are in need of extraction in an attempt to avoid future procedures.

*

I authorize deciduous teeth to be pulled if neccessary.
I do not authorize deciduous teeth to be pulled and understand that the need for a future anesthetic procedure may result.

I have read and understand the nature of the above procedures and give my consent to proceed.

Signature of Owner/Agent*

Date

Comments

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