CANINE SURGERY/SEDATION PREPARATON FORM

CANINE SURGERY/SEDATION PREPARATON FORM
Owner / Agents Name (Print) *
Patient’s Name *
Date of Procedure *

Month Day Year
Date
Surgical or Medical Procedure *
INCLUDED PROCEDURES:
NAIL TRIM: We can perform our most accurate nail trim while your pet is sedated. This service is complimentary when you bring your pet in for surgery. COMPLIMENTARY

INTRAVENOUS CATHETER AND FLUIDS: For increased anesthetic safety, placed before surgery for delivery of fluids and/or medication to maintain blood pressure throughout the procedure. A local anesthetic is used to minimize any discomfort that may be associated with catheter placement. INCLUDED

PRE-SURGICAL VITAL SIGNS CHECK: Prior to beginning your pet’s procedure today we check their vitals to screen for any recent developments that would change our medical plans. COMPLIMENTARY
OPTIONAL, BUT RECOMMENDED PROCEDURES:
(Please read carefully and mark one choice for each item. These may not have been included in your estimate.)

If you have any questions about your options or why a procedure is recommended please ask an ITAH staff member.

PRE- ANESTHETIC TESTING: Since anesthetics are removed from the body through the kidneys and/or liver, it is important to know that internal organ function and blood values are within normal limits. This is best done before the day of the procedure for the most information at the best value. Additionally, an ECG screen read by telemedicine consultants before your pet's procedure helps us check for arrhythmias that can't be heard with a stethoscope or other subtle heart hearth changes that we need to know about before anesthesia.
Do you want your pet to have a pre-anesthetic ECG screening? (Cost - $45) *

Yes No Already Done
Do you want your pet to have a pre-anesthetic blood screen? (Cost - $82) *

Yes No Already done
ANTI-NAUSEA TREATMENT: Nausea can be one of the most unpleasant parts of anesthesia for pets and people. This 24-hour injection of Cerenia® will help your pet feel better, guard against vomiting while your pet is under anesthesia, and get them back to eating and acting normally as quickly as possible. We feel strongly that this drug is a great benefit to many patients, and the cost of the injection is the only reason it is not automatically included with our sedated procedures.
Would you like your pet to be protected with Cerenia® for 24 hours? Cost based on weight: [up to 50lbs = $42] [over 51lbs = $64] *

Yes No
TEMPSCAN® MICROCHIP IDENTIFICATION Prepare for the unexpected retrieval system permanently identifies your pet. The applied microchip and unique identification number used by Animal control and shelters can be used to reunite you and your pet through a national registry of your choice. The new microchips also report internal body temperature when scanned! This price includes lifetime registration in the Home Again database (We pay the $20 registration fee for you). You may change your information at any time at www.HomeAgain.com or by calling 1-888-466-3242.
Do you want your pet to be permanently identified with a microchip? (Cost - $50) *

Yes No Already done
SIGNATURE REQUIRED
This section applies to the entire form: I’ve read the preceding page and selected the options I am most comfortable with. Where noted, I understand that ITAH doctors may require services that I have not requested for the safety of my pet. I agree to pay for services rendered. I have read the foregoing, understand what it says and agree.
Owner/ Agent (Signature) *

Clear
Date *

Month Day Year
Date
Should be Empty:

CANINE SURGERY/SEDATION PREPARATON FORM

INCLUDED PROCEDURES:

OPTIONAL, BUT RECOMMENDED PROCEDURES:

SIGNATURE REQUIRED