Anesthesia Procedures Consent Form

Estimates and Options

Cat Castration
Castration is a procedure performed under general anesthesia during which the veterinarian removes the animal's testicles. The following measures are taken for every surgical patient:

-Pre-Anesthetic Exam: A physical exam where the doctor evaluates your pet's heart, lungs, and general health status.

-Anesthesia and Anesthetic Monitoring: Includes a pre-anesthetic sedative/pain injection, anesthetic induction, and intubation with oxygen and anesthetic gas delivery. All pets are monitored from the beginning to the end of anesthesia by a trained veterinary assistant and vital parameter monitoring equipment.

-Castration Surgery: Performed by a veterinarian with modern techniques that minimize pain and trauma. After the surgery, a therapy laser is applied to decrease pain and swelling and speed healing.

-Pain Management: The pain management protocol may include injectable pain medications, local anesthetics, and take-home medication. The medications used and length of treatment will vary based on the procedure, the degree of pain involved, and any special needs of your pet.

The following is an estimate of the cost of a castration.
Pre-Anesthetic Bloodwork. With advances in anesthesia and surgery, routine procedures have been made 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 assist our doctors with evaluating your pet’s anesthetic risk, we highly recommend that all pets have bloodwork performed prior to anesthesia. This includes a CBC (complete blood count) to evaluate for things such as infection and anemia, a Chemistry to evaluate internal organs such as the liver and kidneys, and electrolyte levels. Detection of these conditions prior to surgery will decrease the risks associated with anesthesia, and if a problem is detected on the bloodwork, the doctor will contact you to discuss any recommended actions prior to proceeding with anesthesia and surgery. Bloodwork may be required for any animal 6 years and older, for certain procedures, or for pets with concurrent illness or disease.*

Please run the pre-anesthetic CBC, ChemPrep, and Electrolytes as quoted in the estimate.I would like to upgrade to a Chemistry Complete for an additional $22.I decline all bloodwork. I understand and accept that there are additional risks associated with anesthesia when undetected disease processes are present.
Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

FeLV/FIV Test $56.58Anal Gland Expression $18.75Microchip Implantation and Registration $42.00Ear Cleaning $19.10None of the above

Estimates and Options

Dog Oral Assessment, Dental Cleaning, and Treatment
An oral assessment and cleaning is a procedure performed under general anesthesia during which oral health is assessed and teeth are cleaned. The following measures are taken for every surgical patient:

-Pre-Anesthetic Exam: A physical exam where the doctor evaluates your pet's heart, lungs, and general health status.

-Pre-Anesthetic Bloodwork: Evaluates organ function, electrolytes, and blood cell counts. Changes in bloodwork may alter how we proceed with anesthesia for your pet, so bloodwork will be run prior to your pet’s procedure.

-Intravenous Surgical Fluids: IV fluids support blood pressure and allow access to a vein if needed in an emergency.

-Anesthesia and Anesthetic Monitoring: Includes a pre-anesthetic sedative/pain injection, anesthetic induction, and endotracheal intubation with oxygen and anesthetic gas delivery. All pets are monitored from the beginning to the end of anesthesia by a trained veterinary assistant and vital parameter monitoring equipment.

-Dental Radiographs: Often diseases of the teeth are hidden beneath the gumline and therefore dental x-rays are taken to fully evaluate the health of each tooth.

-Dental cleaning and assessment: Dental cleanings are done by a veterinarian using an ultrasonic scaler as well as hand scaling beneath the gum line and on all surfaces of all teeth. The pocket between the tooth and gum is measured and the health of each tooth is assessed.

The following is an estimate of the cost of the basic oral assessment and cleaning.
Although every effort is made to salvage teeth, it is sometimes necessary, for the health of your pet, to remove unhealthy teeth that cannot be saved. In these cases, oral surgery and dental extractions will need to be performed.

-Unfortunately, we cannot determine which teeth need to be extracted until the pet is under anesthesia and the tooth has been evaluated thoroughly during the dental cleaning and assessment and with dental radiographs.

-Patients undergoing tooth extractions will receive appropriate pain management, which may include injectable pain medications, local anesthetics, and take-home medication. The medications used and length of treatment will vary based on the procedure, the degree of pain involved, and any special needs of your pet.

-Some patients require additional take-home medications, such as antibiotics.

As you can see from the following estimate, there can be a huge range of added cost depending on the severity of the dental disease and the number of teeth that need to be extracted.

IF YOU HAVE NOT ALREADY RECEIVED ONE, PLEASE BE SURE TO ASK FOR A MORE SPECIFIC ESTIMATE BASED ON YOUR PET'S DEGREE OF DENTAL DISEASE.
Once your pet's dental cleaning, oral radiographs, and assessment have been performed, the doctor will determine if any additional treatments (such as tooth extractions) are recommended. Please choose one of the following to indicate your wishes.*

I authorize the doctor to perform any treatments they determine are necessary.I would like a phone call to discuss the recommended treatments. If I cannot be contacted, please perform the recommended treatments.I would like a phone call to discuss the recommended treatments. If I cannot be contacted, please wake my pet up without the recommended treatments being performed.
Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

Heartworm Test $27.50Anal Gland Expression $18.75Microchip Implantation and Registration $42.00Ear Cleaning $19.10None of the above

Estimates and Options

Cat Oral Assessment, Dental Cleaning, and Treatment
An oral assessment and cleaning is a procedure performed under general anesthesia during which oral health is assessed and teeth are cleaned. The following measures are taken for every surgical patient:

-Pre-Anesthetic Exam: A physical exam where the doctor evaluates your pet's heart, lungs, and general health status.

-Pre-Anesthetic Bloodwork: Evaluates organ function, electrolytes, and blood cell counts. Changes in bloodwork may alter how we proceed with anesthesia for your pet, so bloodwork will be run prior to your pet’s procedure.

-Intravenous Surgical Fluids: IV fluids support blood pressure and allow access to a vein if needed in an emergency.

-Anesthesia and Anesthetic Monitoring: Includes a pre-anesthetic sedative/pain injection, anesthetic induction, and endotracheal intubation with oxygen and anesthetic gas delivery. All pets are monitored from the beginning to the end of anesthesia by a trained veterinary assistant and vital parameter monitoring equipment.

-Dental Radiographs: Often diseases of the teeth are hidden beneath the gumline and therefore dental x-rays are taken to fully evaluate the health of each tooth.

-Dental cleaning and assessment: Dental cleanings are done by a veterinarian using an ultrasonic scaler as well as hand scaling beneath the gum line and on all surfaces of all teeth. The pocket between the tooth and gum is measured and the health of each tooth is assessed.

The following is an estimate of the cost of the basic oral assessment and cleaning.
Although every effort is made to salvage teeth, it is sometimes necessary, for the health of your pet, to remove unhealthy teeth that cannot be saved. In these cases, oral surgery and dental extractions will need to be performed.

-Unfortunately, we cannot determine which teeth need to be extracted until the pet is under anesthesia and the tooth has been evaluated thoroughly during the dental cleaning and assessment and with dental radiographs.

-Patients undergoing tooth extractions will receive appropriate pain management, which may include injectable pain medications, local anesthetics, and take-home medication. The medications used and length of treatment will vary based on the procedure, the degree of pain involved, and any special needs of your pet.

-Some patients require additional take-home medications, such as antibiotics.

As you can see from the following estimate, there can be a huge range of added cost depending on the severity of the dental disease and the number of teeth that need to be extracted.

IF YOU HAVE NOT ALREADY RECEIVED ONE, PLEASE BE SURE TO ASK FOR A MORE SPECIFIC ESTIMATE BASED ON YOUR PET'S DEGREE OF DENTAL DISEASE.
Once your pet's dental cleaning, oral radiographs, and assessment have been performed, the doctor will determine if any additional treatments (such as tooth extractions) are recommended. Please choose one of the following to indicate your wishes.*

I authorize the doctor to perform any treatments they determine are necessary.I would like a phone call to discuss the recommended treatments. If I cannot be contacted, please perform the recommended treatments.I would like a phone call to discuss the recommended treatments. If I cannot be contacted, please wake my pet up without the recommended treatments being performed.
Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

FeLV/FIV Test $56.58Anal Gland Expression $18.75Microchip Implantation and Registration $42.00Ear Cleaning $19.10None of the above

Estimates and Options

Other
Please describe the procedure your pet is having performed:*
Please choose one of the following:*

I have received and approved an estimate describing the expected procedure and associated costs.I have not received an estimate, but would like one prior to the procedure.I have not received an estimate, but do not require one. I prefer to leave the specifics of the procedure up to the discretion of the doctor.
Would you like any of the following additional services performed while your pet is under anesthesia? (Nail trims are included free of charge while under anesthesia.)*

Heartworm Test (dogs) $27.50FeLV/FIV Test (cats) $56.58Anal Gland Expression $18.75Microchip Implantation and Registration $42.00Ear Cleaning $19.10None of the above

Policies, Procedures, and Authorizations

Please read each section, click to acknowledge your understanding, and sign at the bottom
I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, and that I do hereby give Gem City Veterinary Services, their doctors, agents, servants, and/or representatives full and complete authority to perform the procedures described above.
I understand that there is always a risk associated with any sedation or anesthesia episode, even in apparently healthy animals. I also understand that there is always a risk associated with any surgical procedure. I understand these risks include serious bodily injury or death, and no guarantees have been made to me regarding outcome. I understand that unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all costs incurred.
I understand that, for the safety or care of my pet, it may be necessary to provide medical and/or surgical procedures which are not anticipated. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgment. I accept responsibility for any additional charges incurred as a result of these procedures.
I understand that the Gem City Veterinary Services hospital is not staffed 24 hours a day and that if my pet requires an overnight stay, no staff will be attending to my pet overnight.
I understand that payment for this procedure is required the day it is performed. I understand that a monthly service charge of 1.75% or $5.00, whichever is greater, with an additional delinquent fee of $30.00, will be imposed on any outstanding balance. Should my account be referred to an attorney or collection agency, as a result of non-payment, I agree to pay all reasonable attorney fees, court costs, and collection expenses.
If there is anything else that we should know about your pet or about their procedure, please note it here.
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Anesthesia Procedures Consent Form

Owner Information

Pet Information

Estimates and Options

Estimates and Options

Estimates and Options

Estimates and Options

Estimates and Options

Estimates and Options

Estimates and Options

Estimates and Options

Policies, Procedures, and Authorizations