Pre-op Geriatric (over 7) form

Anesthesia & Pre-Anesthetic Testing/Surgery Consent From

Geriatric (7 years)
Owner Name*
Animal's Name*
Please read carefully and sign.

Your pet is scheduled for a procedure that requires anesthesia. Like you, our greatest concern is the well-being of your pet. Therefore, we would like to take this opportunity to discuss pre-anesthetic testing and explain why it is important to the health of your pet.

Before surgery, a veterinarian will perform a complete physical examination. Because there is always the possibility a physical exam alone will not identify all of your pet's health problems, we require a pre-anesthetic profile be performed prior to anesthesia in patients over 7 years of age. These tests are similar to and equally as important as those your own physician would run if you were to undergo anesthesia.

Although we use the latest and safest anesthetics available and perform a pre-anesthetic profile, it is important to understand that these precautions will not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future.

The pre-anesthetic blood tests in patients over 7 years of age (geriatric), includes a complete blood count and 20 organ function tests. The cost for these tests will be $163.45. The pre-anesthetic blood panel is required in patients 7 years old and over because these patients are considered geriatric and are at a greater risk for metabolic disease and overall organ changes.

I authorize the use of anesthesia on my pet. I understand that all anesthesia involves some minimal risk to my pet, and I understand that I assume all risks providing reasonable care and precautions are followed by the attending veterinarian and staff. If any problem develops with my pet in my absence, I request that it be treated as deemed best by the staff veterinarian until I can be reached.
Please choose one*

I would like to discuss pre-anesthetic testing with a veterinarian.My pet has had full bloodwork in the last 3 months, and based on the results may not need further testing. My veterinarian will evaluate and decide if more bloodwork/urine is warranted.I agree to the above anesthetic release and I request that you complete the recommended testing prior to administering anesthesia to my pet.
Signature*

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Phone Number where I can be reached today*
Preferred method of contact (for post surgical updates)*

Phone CallText
Please answer the following pre-surgery questions: During the past week, has your pet exhibited any of the following symptoms:*

Loss of appetiteVomitingBad breathDiarrheaCoughingSneezingExercise intoleranceNoneOther
Has your pet ever had a seizure or convulsion? *

YesNo
List any other serious medical conditions:*
If the doctor determines that your pet's teeth need to be cleaned and loose, painful, or unhealthy teeth need to be removed, would you like it done while your pet is already under anesthesia (time permitting)? (If interested, an estimate can be provided for you.)*

YesNo
If your pet has retained deciduous teeth (baby teeth), which can cause future dental problems, would you like for them to be extracted while under anesthesia? ($12.32 to $24.64 per tooth)*

YesNo
While sedated it is a good time to microchip your pet. Would you like to have this done today for $51.66? *

YesNoMy pet already has one
If necessary, an elizabethan collar will be sent home with your pet. The cost for this is between $11.00 and $31.00 depending on the size needed. These collars are to prevent licking/chewing at the incision site and help avoid removal of the sutures and/or infection.

All surgeries (except feline neuters) will have an intravenous (I.V.) catheter put in one front leg to administer fluids during the surgery and to have access for giving medications. This will require a small amount of hair to be shaved in order to prep the area.
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Anesthesia & Pre-Anesthetic Testing/Surgery Consent From