SWV Authorization for Professional Services

Name*

First NameLast Name

Pet's Name*

Best Phone Number Day of Procedure*

Please enter a valid phone number.

Have you moved? If yes, please update your address here:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email address:

example@example.com

Due to increasing awareness and requests from our clients regarding the use of pain management and pre-anesthetic blood testing for routine procedures or operations, we offer several optional services to increase the margin of safety and comfort to our patients and their owners.

Blood Testing for Anesthetic:

Although current anesthetic agents pose minimal risk to your pet, pre-surgical blood tests may reveal health concerns where modification of anesthetic protocol would be indicated to maximize patient safety.

Most anesthetics are flushed from the body through the liver or kidneys. That is why it is important to know that these organs are functioning properly. Blood tests give us that information thus allowing for the most appropriate and safest anesthetic regime to be administered. These tests are similar to those your own physician would run if you were to undergo anesthesia. Young, healthy pets may only require minimal blood screening, while older pets should have a complete blood panel performed.

• Mini CBC Profile: PCV (Anemia), White Blood Cell Count (Infection) & Red Blood Cell Count (Anemia/Bleeding Disorder), Platelet Count (Clotting Disorder)
• Full Pre-Surgical Profile: Includes the above and adds: BUN and Creatinine (Kidney), ALKP and ALT (Liver), Glucose (Sugar), Total Protein(Dehydration)

Blood Testing for Anesthetic:*

AcceptDecline

Intravenous Catheter Placement:

An intravenous catheter helps us to administer the correct dosage of anesthesia to the patient’s individual needs so that we can use the minimal amount of anesthetic required. It also allows us to administer intravenous fluids and emergency drugs in the unlikely event your pet encounter a problem while under anesthesia. Studies have shown that the presence of a venous catheter significantly reduces risks associated with anesthesia in both dogs and cats. For these reasons, placement of a venous catheter is strongly recommended prior to any anesthetic procedure.

Intravenous Catheter Placement:*

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Microchip Permanet I.D Implant:

These microchips are no larger than a grain of rice and provide permanent identification should your pet become lost or stolen. The chips can be implanted at any time, but doing so while your pet is already anesthetized makes it convenient and totally pain free.

Microchip Permanent I.D. Implant:*

AcceptDecline

Pain Management:

The need of pain management will vary with the patient and the nature of the procedure being performed. An initial pain injection is included during procedures such as spays and neuters. However, we recommend additional pain medication when indicated for a more comfortable, faster recovery and added peace of mind for you.

Pain Management:*

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Deciduous Teeth:

Retained deciduous teeth are those that did not fall out when the adult teeth erupted. Leaving these teeth in place can cause several issues including pain, malocclusion/overcrowding, and excessive tarter buildup leading to periodontal disease and/or the loss of the permanent tooth. If a deciduous tooth has been identifed, it should be extracted.

Extract Deciduous Teeth:*

AcceptDecline

Flea / Tick Policy:

If your pet has fleas or ticks, he or she will be treated at your expense in order to maintain an optimal environment for all patients.

Patients who are on a flea preventative but still have fleas will be administered a dose of Capstar at your expense. Capstar kills adult fleas before they can lay eggs and cause an infestation. The medication begins working within 30 minutes of application and kills over 90% of adult fleas within a few hours. The expense to administer Capatar is $20.

Is your pet on flea control?*

If "other" please specify:

Date last given:

Date

Please list any medications and date/time last given:

Authorization:

I am aware of the risk of this procedure, understand the information presented in this form and give the hospital staff permission to proceed with the above procedure(s) and related services. I assume financial responsibility for all charges incurred and I agree to pay all fees in full upon completion of my pet’s care.

Signature:*

Date of Procedure:*

Date