Surgery/Anesthesia Consent Form

Pet's Name*

Owner's Name*

First Last

Surgical/Anesthetic Procedure

This procedure will include preparation, anesthesia, monitoring, catheterization and fluid support, and pain management. If you would like a detailed explanation of each area covered under the procedure, please see a staff member. An information form is also available for your convenience.

Please check any of the following you would like included with this procedure:*

Pre-Anesthetic Bloodwork: $97.00 (in house, day of procedure) We will perform a full physical examination on your pet before administering anesthesia. However, we highly recommend a pre-anesthetic blood panel be performed. This will ensure that your pet is in a low risk category for anesthesia by screening for medical problems which may not be evident physically but could affect your pet’s recovery from anesthesia and/or surgery (anemia, low-grade infections, kidney or liver disease, blood clotting deficiencies, etc.).
Heartworm and Tick Disease Test: $46.50 For canine pets, a current negative heartworm test (within the last year) is also necessary prior to anesthesia. Undiagnosed heartworm positive canines could pose an anesthetic risk.
Microchip (including registration): $95.00
Express Anal Glands: $33.00
Nail Trim (no additional charge)

AUTHORIZATION - I have read and understand this authorization and consent and authorize the described surgical/anesthetic procedure and anesthesia for my pet. - I have not given my pet any food after 12 AM the morning of the procedure, unless otherwise advised by my veterinarian. I understand that this is important for anesthesia safety.

Signature*

First Middle Last

Please list your name again as agreement to the information listed above

Date*

Monday	8:00am – 6:00pm
Tuesday	8:00am – 6:00pm
Wednesday	8:00am – 6:00pm
Thursday	8:00am – 6:00pm
Friday	8:00am – 6:00pm
Saturday	8:00am – 12:30pm
Sunday	Closed

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Surgery/Anesthesia Consent Form

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Surgery/Anesthesia Consent Form

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