Treatment Consent

325 Yadkin Rd.

Southern Pines, NC 28387

(910) 692-4201

www.longleafanimalhospital.com

Anesthesia/Surgery Consent Form

Client Name*

Patient Name*

Your pet will be undergoing general anesthesia plus a surgical procedure today. In order to identify any underlying abnormalities or blood clotting deficits your pet may have, we require having a pre-surgical blood profile run on your animal prior to anesthesia administration. This consists of a CBC and CHEM 10 or CHEM 17 ( ALT, ALKP, CREA, GLU, TP, and BUN), which will check blood glucose, kidney and liver enzymes.

CBC/CHEM 10/LYTES (healthy animals under 7 years of age) $100.00

CBC/CHEM 17/LYTES (animals older than 7 years of age) $125.00

Procedure(s) Requested*

When did your pet eat last?*

I understand that during the performance of this procedure(s), unforeseen conditions may be revealed that necessitate a change of procedure or additional procedures. I expect the staff at Longleaf Animal Hospital to use reasonable care and judgement in performing the procedure(s). The nature of the procedure(s) and the risks have been explained to me, and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any financial obligation incurred regarding my pet.

Current Medications:

Refills Needed:

YesNo

In the event of an emergency:*

I do authorize CPR or other life saving procedures in the event of an emergency.I do NOT authorize CPR or other life saving procedures in the event of an emergency.

Microchip:*

I would like my pet microchipped today with a HomeAgain microchip. (The enrollment is paid for by the clinic).I would NOT like my pet microchipped today with a HomeAgain microchip.My pet is already Microchipped

Therapeutic lasers use light waves of a specific wavelength to cause photobiomodulation, or the healing of cellular and tissue physiology. The main clinical benefits of laser use in pets include decreased inflammation, decreased pain, improved wound healing, and faster recovery times. The Therapeutic laser add-on is provided to our surgery patients for $25.00

Therapeutic Laser Treatment*

I would like my pet to receive therapeutic laser treatment to assist healing following the procedure.I would NOT like my pet to receive therapeutic laser treatment to assist healing following the procedure.

If your pet is having a tumor/growth removed, we can send it off for histopathology to determine the nature of the growth. This is helpful to determine what, if any, further treatment(s) need to be pursued.

Standard Biopsy/Histology $177.16

Tumor/Growth Histopathology send off*

I would like to have the tumor sent for further analysis today.I would NOT like to have the tumor sent for further analysis today..Not Applicable

Electronic Signature*

My signature above verifies that I am at least 18 years of age and am financially responsible for this pet. I agree to pay for all services rendered necessary for this pet. With this signature, I agree to the terms and services discussed on this consent form.

Best contact name and number:*

You will be notified by text message when your pet is out of surgery.