Surgical Authorization | Veterinarians El Dorado Kansas

Surgery Authorization
Form of Contact on Day of Procedure*
Name*

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YesNo
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Spay or NeuterDental CleaningMass RemovalOther
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Pet Name*
CanineFelineOther
Pet Breed*
Pet Description (Color and/or Markings)
My cat's fur is long.My cat's fur is short.My cat's fur is in the middle.
MaleFemale
Pet Age*
Spay (Choose appropriate weight class)*
Neuter (Choose appropriate weight class)*
YesNo
RabiesFeline DistemperFeline LeukemiaI don't know. Please discuss with me at drop off.
RabiesCanine Distemper-ParvoLeptospirosisBordetellaI don't know. Please discuss with me at drop off.
Yes - 6-monthYes - 12-monthNo - Neither
Yes, I would like this for my dogNo, I would not like this for my dogI don't know. Please discuss with me at drop off.
0-25 pounds +$46.5026-50 pounds +$59.0051-100 pounds +$86.00101-125 pounds +$118.00126-150 pounds +$139.50151-175 pounds +$171.50176-200 pounds +$203.50
0-25 pounds +$92.5026-50 pounds +$118.0051-100 pounds +$171.50101-125 pounds +$219.50126-150 pounds +$251.50151-175 pounds +$284.00176-200 pounds +$316.00
Disclaimers

Please read all of the following statements and respond.
Yes, I have read this statement and I understand.I need more explanation.
Yes, I have read this statement and I understand.I need more explanation.
Yes, I have read this statement and I understand.I need more explanation.
If your pet is to be anesthetized, rest assured that advances in anesthesia and surgery have made routine procedures relatively safe with a low rate of complications. Nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. To avoid these problems, we recommend that all animals be screened prior to anesthesia by means of the following laboratory tests:*

Yes, I have read this statement and I understand.I need more explanation.
Yes, I have read this statement and I understand.I need more explanation.
Yes, I have read this statement and I understand.I need more explanation.
Yes, I have read this statement and I understand.I need more explanation.
Pre-Anesthetic Laboratory Tests/Therapeutic Treatments

Selecting "Yes" indicates that you would like us to perform this test and therefore approve the additional charges. Selecting "No" indicates that you decline testing. Please hover or click on the questions to see additional information.
Blood chemistries, or blood serum tests, evaluate your pet's organ function, electrolyte status, hormone levels, and more. These tests are important for evaluating the health of older pets as well as pets receiving long-term medications and general health before anesthesia.
- The CBC (Complete Blood Count) gives the veterinarian information about your dog's hydration status, anemia, infection, blood clotting ability, and immune system response. When checked before surgery, a CBC can also detect bleeding disorders or other unseen abnormalities.
  - A CBC (complete blood count) is recommended on animals of all ages prior to surgery.
- The 10-panel is a focused chemistry foundation, where we check common kidney and liver enzymes as well as blood glucose.
  - A 10-panel chemistry profile is recommended for all animals under 6 years of age.
- The 17-Panel is a more comprehensive chemistry profile that also checks for pancreatic enzymes, as well as important minerals in your pet's blood
  - For animals over 7 years of age, a 17-panel chemistry profile is mandatory unless previously discussed with the doctor.
We also recommend an occult heartworm test on dogs over 12 months old.
YesNoIf the Dr. thinks it's necessary/Please discuss with me at drop-off
YesNoIf the Dr. thinks it's necessary/Please discuss with me at drop-off
YesNoIf the Dr. thinks it's necessary/Please discuss with me at drop-off
Blood chemistries, or blood serum tests, evaluate your pet's organ function, electrolyte status, hormone levels, and more. These tests are important for evaluating the health of older pets as well as pets receiving long-term medications and general health before anesthesia.
- The CBC (Complete Blood Count) gives the veterinarian information about your dog's hydration status, anemia, infection, blood clotting ability, and immune system response. When checked before surgery, a CBC can also detect bleeding disorders or other unseen abnormalities.
- The 10-panel is a focused chemistry foundation, where we check common kidney and liver enzymes as well as blood glucose
The Complete Blood Panel (CBC + 10-panel) is recommended for 1st time anesthesia, geriatric, or debilitated pets.

The Mini Blood Panel (10-panel) is recommend for all other pets undergoing surgery

We also recommend an occult heartworm test on dogs over 12 months old.
YES, please perform a Complete Blood Panel. +$169.50YES, please perform a Mini Blood Panel. +$70.00NO, I'm refusing to approve any blood tests and accept the inherent riskWhatever the doctor thinks is necessary for the safety of my petPlease discuss further with me at drop-off
Yes +$68.00NoIf the Dr. thinks it's necessary/Please discuss with me at drop-off
Yes +$48.00NoIf the Dr. thinks it's necessary/Please discuss with me at drop-off
Yes +$33.00NoIf the Dr. thinks it's necessary/Please discuss with me at drop-off
Yes +$50.50NoMy Pet is Already MicrochippedIf the Dr. thinks it's necessary/Please discuss with me at drop-off
Yes +$47.00NoIf the Dr. thinks it's necessary/Please discuss with me at drop-off
I have read through the entire form and give my consent to perform anesthesia...
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Surgery Authorization

Disclaimers

Pre-Anesthetic Laboratory Tests/Therapeutic Treatments