ANESTHESIA/SURGICAL CONSENT FORM

 

            DATE:            Today’s EMERGENCY CONTACT #__________________
 
 
Regular VETERINARIAN: ______________________
 
I authorize the above-named veterinarian, and his/her staff to perform the treatment/procedure(s) described below. I have been informed of the reasons for the treatment/procedure(s) along with the expected benefits and risks involved. I am aware of the risk and understand the information presented in this surgery form and give Companion Pet Care Clinic and staff members permission to proceed with the surgery and perform any and all lifesaving procedures should the need arise. I understand that I assume all risks. I am the legal owner or guardian of the above patient. I understand that no guarantee of outcome has been made or implied.  IF FLEAS/TICKS ARE FOUND, YOUR PET WILL BE TREATED AT YOUR COST WITH A DOSE OF FRONTLINE PLUS OF REVOLUTION AS DEEMED APPROPRIATE.
 
Payment for services is due at the time rendered.   Accounts remaining unpaid will incur interest at the rate of 18% per annum plus $5/month billing fee. There will be a fee of $50.00 on all returned checks. Any check returned to us for insufficient funds will be electronically withdrawn for the amount of the check plus the NSF fee of $50.00. If the account becomes delinquent, the undersigned agrees to assume all costs and expenses, including court costs and/or attorney’s fees. I assume responsibility for payment in full upon discharge of my pet.
 
            ___________________________                           _________________
            Signature of owner/authorized agent                                    Date
 
Medical History   Please answer the questions below:
Does your pet have any of the following?
Heart condition?
Respiratory condition?
 Diabetes?
Bleeding disorder or familial history of one?
 Deciduous teeth (baby)?
 In heat/pregnant? Allergies to medications?
Currently on any medications?
On heartworm prevention?
For Cats: aids/leukemia?                       Ever tested for these diseases?
Current on immunizations?
 
 SURGICAL OPTIONS:
 
As with any surgery requiring general anesthesia, certain risks may result in serious complications or even death. To minimize such risk, we offer the following diagnostic and therapeutic options:  Included in the cost of surgery is a rough indicator of anemia and kidney function (PCV/TP & Azo stick). More extensive testing is recommended and priced as follows:
 
Pre-anesthetic lab sent out to an external lab at least 1 day before procedure is $38.84. This is the most cost effective choice.
 
In house on the day of procedure:
 
I. CBC/CHEMISTRY 6/ELECTROLYTES
1. <7yrs old: $94.46
Complete blood cell count, chemistry profile x 6 electrolytes.
Checks proper organ function, anemia, ability to fight infection, proper platelet numbers for clotting, and establishes a baseline for future reference.
 
2. CBC/CHEMISTRY 12/ELECTROLYTES in house
 >7 yrs old: $109.13
Same as above but with more extensive blood testing x 12 electrolytes
 
II. IV CATHETER & FLUID THERAPY $54.45
Maintains blood pressure, replaces lost blood, speeds recovery and quick rapid administration of life-saving drugs in case of emergencies.
 
 
IV. MICROCHIPPING
1 in 3 pets will get lost. Without ID, 90% won’t return home. Micro chipping your pet is a safe, simple and permanent form of pet identification. We would be happy to microchip your pet while under anesthesia today for $46.00. Please ask for a brochure on the enrollment and lost pet insurance through HomeAgain Pet Recovery Service.
 
 
Thank you! Companion Pet Care Clinic
 
Please initial the option that applies:
 
I decline all of the options.         ______
           
Yes, please insert a microchip______
 
I accept the lab work only
As appropriate for my pets age.______
 
I accept the IV fluid therapy only.______
 
I accept the both the lab work and______
Fluid therapy.