Pre-Surgery Consent Form Anthony Wayne

Owner Name*

First NameLast Name

Owner Phone Number*

Please enter a valid phone number.

Pet Name*

Procedure*

Our greatest concern is the well-being of your pet. Disorders of any major organ system cannot be detected unless blood testing is done. Abnormalities of any of these will increase anesthetic risk. For these reasons, we highly recommend pre-anesthetic blood screens.*

Yes, I understand the importance of pre-anesthetic blood screens.

Please select your preferred blood screening option:

Mini pre-surgical profile: Includes screening for liver and kidney functions only. Establishes a baseline for age related changes (cost of this is $67.67)Pre-surgical profile: Includes all of the above plus screening for diabetes, gastrointestinal, and pancreatic diseases. Also includes a complete blood count that screens for anemia, infection, and possible clotting problems which can indicate a serious problem related to bleeding during or after surgery. (cost of this is $132.16)Comprehensive pre-surgical profile: Includes all of the above but in far more detail, with much more in-depth information about each organ's function. (cost of this is $266.40)

IV Fluids given prior and during surgery are STRONGLY recommended for every pet undergoing anesthetic no matter the age or procedure (but required for pets over 10). IV Fluids help maintain normal blood pressure, correct the dehydration from being fasted, increase the metabolism and excretion of the anesthetic by the kidneys, and provide rapid administration of life-saving drugs should an emergency situation develop.

I would like to utilize IV Fluids in my pet's surgical procedure (cost of this is $111.46)

A pre-anesthetic ECG shows any electrical disturbances in the transmission of impulses in the heart, heart enlargement, or arrhythmias. Any of these can increase anesthetic risk.

I would like to utilize an ECG in my pet's surgical procedure (cost of this is $113.12)

Your pet is constantly monitored throughout the entire procedure for blood oxygen content, heart rate, respiratory rate, and blood pressure to ensure all vital signs are normal. If even mild abnormalities are detected by the machines, we will give medication by injection to correct them.

Some minor procedures are more comfortable for your pet if done under anesthesia. Please check all that you would like done.

Microchip I.D. [Petlink] (Cost of this is $38.15)Healing laser post-surgery (cost of this is $21.55)Nail Trim (Cost of this is $6.75)Ear Cleaning (Cost of this is $28.24)Anal Gland Expression (Cost of this is $33.07)Elizabethan Collar [Sent Home] (Cost of this is $12-$22, dependent on size of dog)

Loose or infected teeth will be removed if deemed necessary by the doctor.

Extraction Costs:

Level #1 (Each): $29.64

Level #2 (Each): $39.10

Level #3 (Each): $67.46

Baby Teeth (Each): $29.64 (retained baby teeth will be removed with any anesthetic procedure)

I hereby affirm that I am the owner, or the owner's representative, and hereby give consent to Anthony Wayne Animal Hospital to perform the above stated procedures and treatments to my pets. The nature of the procedure(s) has been explained to me and no guarantee has been made to me as to the result or cure. I understand that there are inherent risks in any anesthetic and / or surgical / medical procedure. These risks as they apply to my animal in its current situation have been explained and discussed with me and / or my agent. I am satisfied with the information I have received and hereby release Anthony Wayne Animal Hospital, its employees, and owners from any liability stemming from any misunderstanding of the above issues of risk. I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforseen operative complications and I understand that the doctor will use all reasonable care and that complications may occur anyway. I am aware that there will be fees involved for any subsequent visits deemed necessary by the doctor. THESE PREMISES ARE NOT ATTENDED 24 HOURS A DAY FOR OBSERVATION OF ANIMALS BY EITHER DOCTORS OR STAFF. I understand that, in the event that I don't pick up my pet at the scheduled time, extra charges will be involved for boarding. I also understand that if I fail to pick up my pet, the animal will be considered abandoned and be removed from the office. I further understand that I am not in any way relieved of the financial obligation incurred as a result of service by this office. I have read the foregoing and I agree.

Signature*

Date*

Date

Pre-Surgery Consent Form

Pre-Anesthetic Bloodwork

Intravenous Fluids

Electrocardiogram

Pulse Oximetry And Blood Pressure Monitoring

Minor Procedures

Dental Procedures

Consent And Release