Southern Crossing AH - Anesthetic Consent Form

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Date* This field is required.

Date

2

Owner/Pet Information* This field is required.

Owner Name

Pet’s Name

Canine/Feline

Phone Number

Email

3

Did your pet eat this morning?

Yes

No

4

What procedures are we performing today? If a mass removal, please indicate the location of the mass(es).

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-INCLUDED-

Pre-Anesthetic Blood Work:

If your pet is to be anesthetized, advances in anesthesia and surgery have made routine procedures relatively safe with low rate of complications. Nevertheless, occasional problems can arise due to pre-existing conditions that are not evident during routine pre-anesthetic physical examination. To avoid these problems, we preform blood work on all patients before administering anesthesia. This blood work checks kidney and liver enzymes, blood glucose as well as a complete blood count.

Pain Management:

An essential part of the humane care of surgical patients is pain management. Pre and post-operative pain control is used on all surgical patients. The cost varies depending on the medications used in hospital and those that are sent home.

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-RECOMMENDED-

Anti-Emetic: $41.50 (0-40lb), $55.00 (41-60lb), $68.50 (61-80lb), $85.50(81-uplb), $126.50 (100-150), $162.50 (150+)
Just like humans, many pets will experience nausea after anesthesia. This can manifest in lethargy, vomiting, poor appetite, or a general appearance of discomfort.
Yes     No *

Home Again Microchip [$91.50]
We also offer microchip insertion and enrollment fee for your pet. While your pet is under anesthesia is the perfect time for insertion.
Yes     No *

I.V. catheter and Fluid Therapy [$51.00]
I.V. Fluid therapy during surgery is an added safety measure. I.V. fluid therapy helps keep the patient hydrated, which may shorten the patient’s recovery period. *ALL MAJOR SOFT TISSUE SURGERIES, ORTHOPEDIC SURGERIES, AND PATIENTS OVER 7 YEARS OLD REQUIRE IV FLUIDS*
Yes     No *

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Procedure Variance

I understand that during the performance of this procedure, unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above. I expect reasonable care and judgment to be used in performing the procedure(s). The nature of the procedure(s) and risks involved have been explained to me to my satisfaction, and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from my obligation to pay for all reasonable costs incurred regarding this animal.

Admission Policy

All animals admitted to the hospital must be current on all required vaccinations and free of external parasites, i.e. fleas and ticks. I hereby give permission to the doctors and staff of SCAH to update my pet’s vaccinations if necessary and to treat any external parasitism noted. I understand that I will be financially responsible for these services. SCAH also reserves the right to assess an aggressive animal fee if my pet poses a safety risk to the staff. Furthermore, SCAH is not staffed after hours. If my pet requires overnight care, I will be referred to the Animal Emergency Center.

I understand that all fees are due at the time that services are rendered. In the event of default or failure to pay, I, the undersigned, agree to pay all attorney’s fees and the collection cost of said debt.

Owner’s/agent signature: *