SEDATION/SURGERY AUTHORIZATION

Sedation/Surgery Authorization Form 2025

Date*

Date

Client Name*

First and Last Name

Contact Cell Number*

Email*

example@example.com

Pet Name*

Procedure*

List Medications your pet is on:*

Type NONE if none

Last given

Type NONE if none

Dose given

Type NONE if none

Pre-Anesthetic - Diagnostic Testing

The Animal Care Center (ACC) recommends pre anethstic blood profile for all sedated procedures. This diagnostice tests basic kidney and liver functions and looks to see if your pet is healthy for the procedure. As such this diagnotic is offered at a low cost. Please review our document "Why Bloodwork" for more information.

Potential Risk - Elective surgeries

Your animal is scheduled for a diagnostic or surgical procedure requiring a general anesthetic or a significant level of sedation. The Animal Care Center (ACC) Improving technology now allows the (ACC) to screen via pre-anthestetic blood profile for more subtle and sub-clinical internal changes that may complicate induction and maintenance of anesthesia. In elective surgeries, abnormal values may warrant additional testing and delaying a surgical procedure until the underlying issues can be identified, compensated for or corrected. Additionally, the result of any testing can be a valuable asset to the health care database of your animal in the event of an illness later in life. The ACC staff are committed to achieving 100% success in every anesthetic or surgical procedure performed; however, no outcome can be guaranteed 100%.

Minimum pre-anesthetic testing (Chem 6, PCV) Low Cost: $ 58.75*

YesNo

Complete blood work (CBC, Chem 12, PCV) Cost: $ 138.00*

YesNo

Additional intravenous fluids during surgery (included at no charge for Dentals & K-9 Spays). Cost: $ 76.75*

YesNo

Additional services which may be requested while your pet is under anesthesia providing the Dr. deems them appropriate.

Nail Trim: $9.00Anal Gland Expression: $15.00Ear hair plucking/ear cleaning: $9.00Microchipping: $33.99

Permission to perform surgery or other invasive procedure

I am the owner or the agent for the owner of the animal described above, and I have the authority to execute this consent. I hereby consent and authorize the Animal Care Center to receive, prescribe for, treat for, or operate on my pet, and I fully understand that there may be risks associated with the procedure(s) and/ or anesthesia. Possible complications of surgery include bleeding and infection, damage to other internal organs, blood clots, allergic or other bad reactions to one or more of the substances including anesthetic agents used in this surgery, and death of your animal. I further understand that during the course of the operation or procedure, unforeseen conditions may arise that may necessitate the performance of additional procedures.

I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. Any estimate or charges for the presently planned procedure are only an approximation. This is only an estimate, final charges can only be calculated at the end of treatment. I have read the foregoing statements and agree to these terms.

Signature*

Pre & Post Surgery FAQ's

FAQ's Pre Surgery

FAQ's Post Surgery