ITAH CANINE SURGERY/SEDATION PREPARATION FORM

SURGERY/SEDATION PREPARATION FORM

Please submit this form no later than 3 days prior to your pet's scheduled surgery. Thank you for helping us plan for your pet's needs!
Owner/Agent Name*
Patient's Name*
Surgical or Medical Procedure
Date of Procedure*

MonthDayYear
Date
INCLUDED PROCEDURES:
NAIL TRIM: We can perform our most accurate nail trim while your pet is sedated. This service is complimentary when you bring your pet in for surgery. COMPLIMENTARY

INTRAVENOUS CATHETER AND FLUIDS: For increased anesthetic safety, placed before surgery for delivery of fluids and/or medication to maintain blood pressure throughout the procedure. A local anesthetic is used to minimize any discomfort that may be associated with catheter placement. INCLUDED

PRE-SURGICAL VITAL SIGNS CHECK: Prior to beginning your pet’s procedure today we check their vitals to screen for any recent developments that would change our medical plans. COMPLIMENTARY
REQUIRED PROCEDURES FOR BRACHYCEPHALIC BREEDS:
Due to the unique airways of brachycephalic (short snout) breeds, the risk of complications with anesthetic procedures is marginally higher. I understand that my veterinarian will help minimize these higher risks by providing extra anesthetic support measures in the form of pre-oxygenation, metoclopramide prokinetic medication, and airway suction in recovery. The cost of this bundle of services will range from $65 to $95 and will be my responsibility.
OPTIONAL, BUT RECOMMENDED PROCEDURES:
(Please read carefully and mark one choice for each item. These may not have been included in your estimate.)

If you have any questions about your options or why a procedure is recommended please ask an ITAH staff member.

PRE- ANESTHETIC BLOOD SCREEN: Since anesthetics are removed from the body through the kidneys and/or liver, it is important to know that internal organ function and blood values are within normal limits. Testing for anemia and platelets is important for clotting and is included with this testing. Required within 3 months of procedure for pets 8 years of age or older.
Do you want your pet to have a pre-anesthetic blood screen? (Same day cost - $150; Prior to surgery day cost - $110.00)*

YesNo
PRE- ANESTHETIC ECG SCREEN: An ECG screen read by telemedicine consultants before your pet's procedure helps us check for arrhythmias that can't be heard with a stethoscope or other subtle heart health changes that we need to know about before anesthesia.
Do you want your pet to have a pre-anesthetic ECG screening? ($59.00)*

YesNo
ANTI-NAUSEA TREATMENT: Improve your pet's recovery with a 24 hour anti-nausea dose of Cerenia® to prevent vomiting and get them back to eating and acting normally as quickly as possible.
Would you like your pet to be protected with Cerenia® for 24 hours? Cost based on weight: [up to 50lbs = $58.50] [over 51lbs = $79]*

YesNo
TEMPSCAN® MICROCHIP IDENTIFICATION: Prepare for the unexpected...HomeAgain companion animal retrieval system permanently identifies your pet. The applied microchip and unique identification number used by Animal control and shelters can be used to reunite you and your pet through a national registry of your choice. The new microchips also report internal body temperature when scanned! This price includes lifetime registration in the Home Again database (We pay the $20 registration fee for you). You may change your information at any time at www.HomeAgain.com or by calling 1-888-466-3242.
Do you want your pet to be permanently identified with a microchip? (Cost - $60.00)*

YesNo
DENTAL PROCEDURES ONLY:

A surprising number of dental problems (abscesses, root resorption, etc.) can occur under the gumline and go unidentified even after careful examination. Routine full mouth dental radiographs allow us to make the best treatment decisions for each tooth. The cost of any additional anesthesia time require is included.
Do you want us to perform a full-mouth dental radiograph on your pet? (Cost - $120)

YesNo
DENTAL PROCEDURES ONLY:

We can apply OraVet Barrier Sealant as the last step in your pet's dental cleaning. OraVet creates an invisible barrier that prevents plaque and tarter forming bacteria from attaching to the teeth for up to 2 weeks. At that point, your pet's gums will be healed and ready to start a home dental care program.
Do you want your pet to have a sealant application? (Cost - $25.00)

YesNo
ACKNOWLEDGEMENTS: (Please read and initial each statement, then sign below)
I understand that Indian Trail Hospital does not extend credit and agree to pay this account in full when services are rendered.*
Please initial
I am aware that there are potential risks with the use of sedatives and anesthesia, and I release the veterinarian and staff of responsibility in the consequences of their use. I authorize Indian Trail animal Hospital to administer proper emergency medical intervention if needed.*
Please initial
I understand that the contact person I list at drop-off will be responsible for making medical and financial decisions for my pet and family.*
Please initial
I understand that as a part of this procedure, fur may be shaved from one or both front legs for sterile IV placement and/or from the body for surgical procedures.*
Please initial
SIGNATURE REQUIRED
This section applies to the entire form: I’ve read the preceding page and selected the options I am most comfortable with. Where noted, I understand that ITAH doctors may require services that I have not requested for the safety of my pet. I agree to pay for services rendered. I have read the foregoing, understand what it says and agree.
Owner/ Agent (Signature)*

Clear
Date*

MonthDayYear
Date
Should be Empty:

SURGERY/SEDATION PREPARATION FORM

INCLUDED PROCEDURES:

REQUIRED PROCEDURES FOR BRACHYCEPHALIC BREEDS:

OPTIONAL, BUT RECOMMENDED PROCEDURES:

ACKNOWLEDGEMENTS: (Please read and initial each statement, then sign below)

SIGNATURE REQUIRED