Pre-Anesthetic Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pets before your visit.

Pre-Anesthetic Consent Form

We have your pet here today for a procedure that needs to be under anesthesia. In addition to the pre-anesthetic examination, we advise the following screening measures to assist in lowering the risks related to anesthesia use.

Owner's Name *

First

Last

Patient's Name *

Email *

Date *

Please read through each service carefully and mark next to any procedures you would like to accept or decline.

Pre-Anesthetic Blood Screen: This will alert us of many potential liver, kidney, and/or blood cell problems that could complicate anesthesia ($103.00). *

I accept
I decline

Complete Blood Screen: This is a more comprehensive version of the pre-anesthetic blood screen that will alert us of potential organ failure or blood cell problems that could complicate anesthesia ($173.50). *

I accept
I decline

Heartworm Test: Heartworms can cause blood clotting, blood pressure, and other serious cardiovascular problems during anesthesia ($40.50). *

I accept
I decline

Intestinal Parasite Screen: Some intestinal parasites interfere with your pet's ability to control blood loss during and after surgery ($23.25). *

I accept
I decline

Harmony Laser Treatment: Postoperative therapeutic laser treatment to optimize your pet's comfort level ($50.00). *

I accept
I decline

Save This Life Microchip: Pain-free placement of a microchip that includes a lifetime registration, a searchable ID number, an ID tag, and a $1000 Pet Health Insurance policy if your pet is injured while lost ($25.00). *

I accept
I decline

Emergency Care: This will allow us to administer treatment if life-saving measures are deemed necessary during your pet's procedure. Declining this service will issue a Do Not Resuscitate order for your pet on this visit. *

I accept
I decline

I understand that these are offered in addition to the estimated cost of today's procedure, and I accept the charges listed by each procedure. I understand the risks associated with the use of general anesthesia and the risks associated with declining any of the above procedures. *

I have read and understand

Signature of Responsible Party *

Clear Signature

Phone *

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Pre-Anesthetic Consent Form

Pre-Anesthetic Consent Form

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