Surgical- Feline + Bloodwork

Surgical Procedure & Pre-Operative Diagnostic Consent Form

Lifetime Pet Center of New Richmond
Please select at which hospital your pet will be receiving treatment/ undergoing surgery: *

New Richmond, (513)553-9954, 1044 Old US 52, New Richmond, OH 45157
Today's Date *

Month Day Year
Date
Owner's Name *

First Name Last Name
Best Contact Number for Today *

Area Code Phone Number
Secondary Contact Number

Area Code Phone Number
Do you prefer a phone call or text message in the event we have questions during the procedure and for Dr. Miller's post-surgical update? *

Phone Call Text Message No Preference
Patient Name *
Species *

Dog Cat
Sex *

Male Intact Male Neutered Female Intact Female Spayed
Does your pet have any known allergies? *

Yes No
If your pet has known allergies please list them below (food, medications, anesthesia, vaccines, etc.).
Please confirm your pet has not had any food or snacks since before midnight last night (the night before the procedure, a very small amount of water is ok). *

My pet has not had any food or snacks. My pet ate this morning.
Is your pet doing well at home or do you have any concerns we should be aware of before the procedure today? (Select all that apply) *

My pet is doing well and I do not have any concerns. My pet has experienced vomiting/diarrhea/coughing/sneezing (any or all) within the last several days. My pet has been lethargic/appetite is off/ water intake is off (any or all) within the last several days. My pet is experiencing other symptoms not listed above that I would like Dr. Miller to address today.
Please list your pet's current medications and supplements below, their dosages, the frequency you give them, and when they received their last dose. If they are not on any current medications please type in "N/A" or "no medications" below. *
I hereby consent and authorize Lifetime Pet Centers to prescribe for, treat, or operate upon my pet (listed above). I have been advised of the risks associated with treatments and/or surgery. It is thoroughly understood that I assume all risks and will take responsibility for payment of services rendered. Please sign your initials in the space below to acknowledge the above. *
The Lifetime Pet Center of New Richmond & Williamsburg will use all reasonable precautions against injury, theft, escape, or destruction of the animal(s) listed above, but will not be held responsible in any manner whatsoever on account of the care, treatment, or safekeeping of the animal(s) above described, as long as acceptable standards of veterinary medicine have been followed. Please sign your initials in the space below to acknowledge the above. *
It is also noted that my pet will be vaccinated if medically neccessary or if recommended by the prescribing doctor in order to protect the safety of my pet and the staff handling my pet. Please note that rabies vaccination is required by county law. In addition, if my pet is found to have fleas or other parasites while in the hospital, s/he will be treated accordingly as seen fit by the doctor and staff. Please notify us if your pet has any allergies or drug sensitivities. Please sign your initials in the space below to acknowledge the above. *
After reading the above, I have signed to acknowledge receipt and understanding. *

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Your cat is undergoing surgery today. We may discover additional conditions about your cat while s/he is under anesthesia, which can incur additional charges. Please indicate how you would like us to handle these situations should they occur: *

Do the procedure regardless of cost. Call with an estimate for additional charges. If we are unable to reach you we may perform the procedure. Call with an estimate for additional charges. If we are unable to reach you we may not perform the procedure.
Additional Procedures/ treatments that we can perform while your cat is under anesthesia: (Can select multiple) *

Update Due Vaccines (Written proof of rabies is REQUIRED for all pets.) Sub-cuticular (under the skin) Sutures (If Applicable) $29.50 Additional Pain Control (Topical Application of Zorbium, 4 day control) $40.78 Additional Pain Management (Nerve Block with Nocita, 4 day control) $245.00 Microchip Placement (Includes lifetime registration) $60.00 IV Fluids (REQUIRED for all pets of 6 years of age and older, or any pets with additional health concerns. Longer procedures also require IV fluid therapy and support.) $66.43 Toenail Trim (No charge w/ anesthetic procedures) Ear Cleaning $26.50 No Additional Services (unless required)
You may have a choice for post-surgical pain care for your cat. Please choose your preference below: *

Onsior Chewable Tablets- given at home orally for three days after the procedure. $24.94 Zorbium Topical Solution- applied in-house by staff before discharge and provides three days of pain control at home. $40.78
Please note: bloodwork may be required for your pet. The form is on the next page.
Would you like an estimate for today's procedure (if you haven't already been provided one)? *

Yes No I already have an estimate.
Please provide an email address if you would like an estimate.
example@example.com
By signing below, you acknowledge the estimate (if requested) for the procedure is not a guaranteed price for services. There are often unforeseen circumstances that could result in an increased cost for the procedure we are performing today. We will make a reasonable effort to inform you and gain consent for additional services before proceeding, barring a life saving emergency. If you have any questions or concerns please speak with a staff member before your pet's procedure.
Signature *

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Your cat is scheduled for general anesthesia/ or sedation today. We recommend a pre-anesthetic blood profile regardless of age to ensure your cat is healthy enough to undergo this procedure. We process all blood samples in-hospital and will have results in under 10 minutes. These tests resemble those that your own doctor would require before you underwent an anesthetic procedure. In addition, these test results will serve as reference values should your cat become ill in the future.

Description of tests:

FeLV/FIV Combo Test

This test is recommended for all cats that have not been tested previously, especially kittens and previously stray cats. Both FeLV and FIV are highly communicable diseases that decrease a cat's ability to fight infections and illness.

Comprehensive Profile & Complete Blood Count (CBC)

A comprehensive profile is recommended for all cats that have not had blood work done in the last year. This profile is REQUIRED for all cats that are 6 years of age or older or if they are ill . For older cats it can be done up to two months prior to the procedure. (It includes electrolyte levels, liver and kidney function, blood glucose, white and red blood cell count, and more.)

Thyroid/ Cholesterol Panel

This test may be recommended for your cat dependant on other health concerns. We will notify you if the doctor recommends this test.
Please select which panels you would like your cat to have done today prior to the procedure. (Note: some may be required, as described above). *

FeLV/FIV Combo Test ($71.96 or $51.96 w/ other bloodwork) Comprehensive Profile & CBC ($95.50) Thyroid/ Cholesterol Panel ($58.90, or $38.90 w/ other blood work) None (Please note you may not be able to decline bloodwork and it may be required based on your cat's age and general health status)
If your cat has had blood work done with normal results within the last two months, the blood work for this procedure may be waived. If your cat is 5 years of age or under, it may also be waived.

By declining pre-anesthetic blood work for your cat you understand and assume all risks involved related to not performing the recommended testing before an anesthetic procedure. Cats can have underlying health concerns that do not show obvious symptoms, which can lead to anesthetic complications, and in some instances, death.
By signing below, I agree: *

I am declining the recommended bloodwork for my cat, regardless of risk. I have authorized the bloodwork above.
Signature

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Surgical Procedure & Pre-Operative Diagnostic Consent Form