Anesthesia Consent Form Anesthesia Consent Form Name * Name First Name First Name Last Name Last Name Email * Phone * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Has your address or phone number changed? * Yes No Pet's Name * Age * Weight * Procedure(s) Requested * When did your pet last eat? * When was your pet last given Heartworm Prevention? * When your pet is waking up from their procedure, would you prefer text or a phone call? * Text me Call me Pre-Anesthetic Blood Testing Our greatest concern is the well being of your pet. We will perform a physical examination before administering anesthesia. However, disorders of the liver and kidneys are not detected unless blood testing is done. Abnormalities may increase anesthetic risk. For these reasons we require pre-anesthetic blood screens for general anesthesia. An ECG is also recommended for pets to detect abnormal rhythms of the heart which can be present without a heart murmur. Please select one of the following: * Chemistry Profile + PCV(IH) ,CBC(send out) ECG $481.75 Chemistry Profile + PCV(IH), CBC(send out) $367.75 ECG $114 Already Performed The doctor reserves the right to refuse to do any surgery without any blood work being done. Convenia Convenia is an injectable antibiotic that is proven safe and effective. A single injection of Convenia is equivalent to 14 days of oral antibiotics. THE ADVANTAGE….. no missed doses. Choose the convenient way to medicate your pet. If the doctor feels an antibiotic is not indicated, it will not be given. Convenia * YES, I would like my pet to receive Convenia today. No, I do NOT want Convenia. 1 – 20 pounds $119 21-40 pounds $183 41-60 pounds $229.75 61-80 pounds $266 Microchipping * YES, I would like my pet microchipped today. NO, I would not like my pet microchipped today. Permanent Microchip Identification System designed to identify lost pets and reunite them with their owner. (First year registration included. $19.99 savings.) $73 + tax Additional Services (optional) Anal gland expression - $48 Growth removal (price varies) Ear cleaning - $63 All services are performed while your pet is under anesthesia. Nail Trim (+ tax) * I would like my pet’s nails trimmed while they're asleep - $20 + tax I would like my pet's nails cut and filed while they're asleep. This procedure rounds the edges of the nail so they are not as sharp. - $40 I would like my pet’s nails cut past the quick while they're asleep. This procedure is ideal for dogs whose nails are too long. A topical anesthetic is applied to lessen pain and stop the bleeding. (This procedure will not be performed without anesthesia and will require pain meds to go home) - $62 NO, I do not want my pet's nails trimmed. Proheart (Canines only) Proheart is an injection that protects your pet from heartworm disease. Available in a 6 or 12 month injection, it will alleviate the need to remember a monthly pill. Pets less than a year old, we give Proheart 6.Pets one year and older, we give Proheart 12. Would you like us to give your dog Proheart? YES, please give today NO, they are already on Proheart NO, I do not want Proheart today Dog's Age * Less than a year old One year or older Dog's Weight * 5-25 Pounds - $93 26-50 Pounds - $111 51-75 Pounds - $155.50 76-100 Pounds - $178 101-125 Pounds - $196 126-150 Pounds - $232.50 151-175 Pounds - $268.25 176-200 Pounds - $299 Dog's Weight * 5-25 Pounds - $153 26-50 Pounds - $191 51-75 Pounds - $264 76-100 Pounds - $280 101-125 Pounds - $339 126-150 Pounds - $406 151-175 Pounds - $473 176-200 Pounds - $529 Emergency Contact Information It is crucial that we have a number to reach in case any additional procedures are needed/recommended by the doctor or if an emergency occurs while your pet is under anesthesia. Emergency Phone * ******Please read carefully ****** If the hospital or staff calls and cannot reach me by phone, I consent to the following: * Do whatever is necessary at this time to avoid a second anesthetic procedure. If for some reason we cannot reach you to obtain full consent for any extra procedures, you consent to pay up to [disclose amount below] over the initial estimate. Any procedures over this amount will NOT be performed unless we can reach you. Do NOT perform any procedure that has not been discussed previously. If any extra procedures are deemed necessary by the doctor, we will attempt to reach you on your emergency number. We will wake your pet up 10 minutes after our attempted contact and any additional procedures will be postponed. How much do you consent to pay over the initial estimate. * Authorization to Perform Surgery/Treatment I authorize the veterinarians and staff of Advanced Pet Care of Clear Lake to perform the procedure is described above. I understand that unforeseen complications may arise during the anesthetic period, including loss of life. I acknowledge and understand that no guarantee or warranty can ethically be made regarding results or outcome of this case. In the event of an emergency, I authorize the clinic staff to perform any procedures they feel are necessary for the well being of my pet until communication is established with me. I understand that I assume financial responsibility for all services rendered. Signature * signature keyboard Clear Submit If you are human, leave this field blank.
