Owners Name: _____________________ Pet’s Name:
Contact Information: _________________________,
Please read and Initial each line: (FULL DEPOSIT IS REQUIRED & MEDICATION ARE ADDITIONAL COST)
I certify that I own the above described animal and I am 18 years of age or over and Authorize the veterinarians at South Bay Veterinary Hospital to perform the above procedure (s).
I understand that there are inherent risks associated with anesthetic, medical and surgical procedures, including death and I am encouraged to discuss any concern I have about those risks with the attending doctor before the procedure (s) is/are performed.
In the event of an emergency, the hospital will make every reasonable attempt to contact me so that I am aware of thesituation and may be involved in medical decisions. In the event that I can not be reached I authorized the veterinarians at SBVH to initiate care to address these complications should they arise while under their care. I also agree to pay for such services.
Pre-Anesthetic blood test is recommended for all pets undergoing general anesthesia. It is required for all pets 6 years of age and older*. This blood work allows your veterinarian to assess your pet's overall health, ensuring that your pet is a good candidate for anesthesia. These tests are at extra cost. Please, initial which blood panel to be done:
CBC blood test (A complete blood count assesses the cells that are present in your pet's blood. Abnormalities in your cell counts may indicate underlying disease and affect your pet's surgical/anesthetic risks.)
6 panel blood test (Establish a baseline and monitor NSAID therapy. Ideal for identifying liver damage; Albumin, phosphatase, ALT, BUN, GGT, total bilirubin, triglycerides)
17panel bloodtest (It checks for Electrolytes, Kidney Function, Liver Function, protein, glucose, cholesterol, calcium, lipade, etc...)
4 DX (blood test that checks to see if your dog has antigen to heartworm disease or antibodies to one of the five tick-borne diseases (Ehrlichia canis, Ehrlichia ewingii, Borrelia burgdorferi, Anaplasma phagocytophilum and Anaplasma platys)
I declined a recommended pre-anesthetic blood test for my pet and requested that you proceed with anesthesia. I understand that a medical condition may exist which would be impossible to identify during a physical examination alone. I understand that my pet’s health could be at risk if such a condition goes undetected when my pet is placed under anesthesia. I also understand that performing these blood tests reduces the risk but does not eliminate the potential for complications.