Galesburg Animal Hospital - Pre-Anesthetic Form

Client Name*

Pet Name*

Your pet is scheduled for a procedure that requires anesthesia/sedation. There is a possibility that physical examination alone will not identify all of your pet’s health risks, so we strongly recommend a pre-anesthetic profile be performed prior to anesthesia/sedation. This testing is similar to those your own physician would run prior to anesthesia.

It is important to understand that a pre-anesthetic profile does not guarantee the absence of complications that may arise during anesthesia. It may, however, help identify medical conditions that could increase that risk, and require further treatment.

The testing we recommend for young, apparently healthy pets is:

• BUN, Creatinine, ALKP, ALT, Glucose, Total Protein, Electrolytes
(kidney health, liver health, diabetes/sugar levels, hydration status)
• CBC (anemia, infection, clotting)

For services listed above, $220

I understand that a medical condition may exist that physical examination alone may not identify, and it may increase my pet's anesthetic risk. I acknowledge that if such a condition goes undetected, unforeseen complications may occur during anesthesia/sedation.

Pre-anesthetic testing

Please complete pre-anesthetic testing prior to anesthesia/sedation for my pet.I decline pre-anesthetic/sedation testing at this time and request that you proceed.

In addition, we offer post-operative pain management and laser therapy for applicable surgeries. We believe these facilitate a smoother recovery for your pet. There is an additional charge for these services.

Please add post-operative pain care package ($50-70)*

ACCEPTDECLINE

Please perform a laser therapy treatment ($20-40)*

ACCEPTDECLINE

Microchip: ($40) Permanent form of identification to help ID your pet in the event they become lost or stolen.*

ACCEPTDECLINE

Signature

Date of surgery or procedure appointment:

Date

Please verify that you are human*

Pre-Anesthetic/Sedation Testing Consent