Surgical Authorization Form

Name or Owner/Agent:

Name of Pet:

Canine or Feline?

CanineFeline

Sex:

MaleFemale

Age:

I am the owner/agent for the above described animal, and have the authority to execute this consent. I hereby consent and authorize Geneva Lakes Animal Hospital to perform the following procedure(s):

The nature of such services has been described to me to my satisfaction and I realize that neither guarantee nor warranty can ethically or professionally be made regarding the results of care. These options are in addition to the basic procedure cost.
I understand that anesthesia carries some risk; therefore, blood testing is recommended before general anesthesia. The anesthetic agents are removed from the body by the liver and kidneys, so it is important for us to know before anesthesia that these organs are functioning properly. Blood testing helps us make this determination and is recommended for all pets, especially those pets that are 7 years of age or older.

Pain management protocol is included with all routine spays and neuters.

PRE-ANESTHETIC BLOOD TESTING
Ages <4 years: Complete Blood Cell Count: assesses anemia, infection, clotting cells Chemistry/Electrolytes: 10 test profile that screens the kidneys, liver, hydration status, and blood glucose $87.50

Ages >4 years: Complete Blood Cell Count: assesses anemia, infection, clotting cells. Chemistry/Electrolytes: 15 test profile that screens the kidneys, liver, pancreas, hydration status, blood glucose, and certain cancer indicators. $98.50

Pre-Anesthetic Blood Testing:

AcceptDecline

LASER SURGERY is now available for our patients. This technology allows for little or no blood loss, little or no surgical site swelling, and less post-operative pain. This allows us to offer the best possible care to our patients.

AcceptDecline

Elizabethan Collar (E-collar/Cone) is recommended for most surgical procedures to prevent your pet from causing trauma to the incision site as it heals. We will custom size a see-through cone for your pet to insure optimal fit and comfort. (This is mandatory for certain surgical procedures – we will inform you if this is the case.)

AcceptDecline

Please List ANY and ALL medications/supplements your pet is currently taking. Please ensure to include the strength (mg/ml) and frequency given (once daily, twice daily, etc):

It is often an opportune time to perform other procedures while your pet is under anesthesia.
Please review and authorize any additional procedures requested for your pet:

DOGS: All pets due for their annual exam, or pets we have never examined before, will receive an exam prior to any surgical procedure at the cost of $57.25

Heartworm/Tick Panel Test: $92.50

YesNo

Distemper Combo 1 year: $37.95

YesNo

Distemper Combo 3 year: $58.60

YesNo

Puppy Distemper 1st-3rd: $32.50

YesNo

Rabies Vaccine 1 year: $32.00

YesNo

Rabies Vaccine 3 year: $42.00

YesNo

Lyme Vaccine: $44.00

YesNo

Bordetella (Kennel Cough): $36.00

YesNo

Flu Vaccine: $46.50

YesNo

Lepto Vaccine: $27.50

YesNo

CATS: All pets due for their annual exam, or pets we have never examined before, will receive an exam prior to any surgical procedure at the cost of $57.25

Distemper Combo 1 year: $34.50

YesNo

Distemper Combo 3 year: $52.00

YesNo

Feline Leukemia Vaccine: $33.00

YesNo

Rabies 1 year: $32.00

YesNo

Rabies 3 year: $42.00

YesNo

Feline Triple Test (Feline Leukemia/FIV/Heartworm): $66.00

YesNo

DOGS/CATS:

Fecal Exam (intestinal parasite screen): $40.00

YesNo

Microchip with services: $49.50

YesNo

Nail Trim: $25.00

YesNo

Ear Cleaning: $28.00

YesNo

Anal Sac Expression: $41.50

YesNo

I accept financial responsibility for all services rendered, and understand that payment is due at the time of discharge. Any additional medications or supplies purchased will be at an additional charge. Please note that prices are subject to change.

Phone number(s) where you may be reached today:

Geneva Lakes Animal Hospital Surgical Authorization Form