Surgery Authorization Form

I, First Name* Last Name* do hereby give my consent and authorize Angel Fire Small Animal Hospital, its doctors and staff to receive, prescribe for and/or anesthetize my pet, Pet's Name* for a * on Date*.

Other:

*ANESTHETIC/SURGICAL RISKS: These may include and are not limited to hemorrhage, hypothermia, decreased respiratory rate, heart complications, death, post-operative complications (i.e. surgical site breakdown, secondary infections), etc. I understand these risks and that the doctors and supporting staff of Angel Fire Small Animal Hospital will do their best to minimize said risks. I also understand the estimated cost of surgery, hospitalization, medication, and other services are approximate, but unforeseen circumstances may require additional services. Initials*

*PRE-ANESTHETIC BLOODWORK: Your pet’s risk of complications during and after anesthesia and surgery is tremendously greater if there is pre-existing organ disease, malfunction, or failure. We strongly encourage bloodwork before anesthesia and surgery to help rule out these problems or identify them and devise an alternative treatment plan to meet your pet’s unique needs. These blood panels provide immensely valuable information.*

I AGREE to the pre-anesthetic bloodwork.I DECLINE the recommended pre-anesthetic bloodwork and request that you proceed with anesthesia. I understand that a medical condition may exist which would be impossible to identify during a physical exam alone. I understand that my pet’s health could be at risk if such a condition goes undetected when my pet is placed under anesthesia.

Bloodwork Options:

Juvenile Profile (0-3 years of age): $50.00General Profile (4 years of age and older): $115.00

*ALL pets undergoing anesthesia will have an IV catheter placed. It is necessary to shave the hair on one or more legs for this procedure. IV fluids will be administered to your pet if medically necessary. *ALL pets will also receive pain medication when needed. Initials*

*HISTOPATHOLOGY (Growth Removals ONLY): When removing growths, especially growths we suspect are cancerous, we highly recommend sending the growth in for histopathology. The histopathology report will tell us what kind of growth it is, how aggressive it is, how likely it will metastasis (spread to other parts of the body), if we have completely removed the growth, or if it is likely to come back, etc. The cost is between $140 to $200.*

Yes, I AGREE to send for histopathology.No, I DECLINE to send for histopathology.Not Applicable

*DENTAL PROCEDURES ONLY: If your pet is here for a teeth cleaning and it is medically necessary for the health of your pet for teeth to be extracted, there will be an additional charge for extractions.*

I agree to extractions as medically necessary.Not Applicable