Surgical Consent Form and Pre-Anesthetic Testing

Please note: A seperate form must be filled out for each pet.

* -All fields are required except Procedure Date, E-Mail Address and Specific Veterinarian.
Location of surgery:
Client Name:
Pet's Name:
Type of Procedure:
Procedure Date:
E-Mail Address:
Specific Vetarinarian?
Phone number where you can be reached today:  
I hereby authorize and direct the veterinarians of City Veterinary Center to perform the above procedures.
Accept

Our greatest concern is the safety of your pet. Before anesthesia and surgery, we recommend a pre-anesthetic blood profile for all patients in order to maximize safety. This test could alert us of possible unforeseen problems which might complicate the anesthesia or the procedure. This test is similar to those your physician would run prior to surgery. We regularly detect common ailments in their earliest stages such as diabetes, kidney disease, liver disease, and anemia through this testing. Since your pet’s health can change without symptoms, recent blood work is important. If blood work has not been done in the past month, we recommend it be done again prior to surgery. It can be done in our clinic lab the morning of the surgery.

We recommend one of the following:
Panel #1: Healthy Patients 0-4 Years Of Age
  Blood Panel Minor
CBC (Complete Blood Count)
BUN & Creatinine (kidneys)
Glucose (Sugar)
ALT & Alk Phos (liver)
Total proteins
  Cost: $62.25

Panel #2: Healthy Patients 5-8 Years of Age
  Blood Panel Major
CBC (Complete Blood Count)
BUN & Creatinine (kidneys)
Glucose (Sugar)
ALT & Alk Phos (liver)
Total proteins
Albumin (liver & Kidneys)
Globullin, Cholesterol
Blood calcium
Electrolytes
  Cost: $86.25

I have elected to refuse the recommended pre-anesthetic bloodwork at this time and request that you proceed with anesthesia. Should complications arise, I assume full responsibility.

Please refer to my pet’s medical records for current blood tests (CBC and serum chemistries).


IV Catheter and IV Fluid Support

In addition to pre-anesthetic blood testing we recommend IV Catheter and IV fluid support during surgery. Intravenous fluids help maintain your pet’s blood pressure during surgery and allow direct access to a vein in case of emergency.

I accept IV fluids ($48.50).
I decline.


Oral Pain Medication
Not all patients require post-operative pain medications, but some may benefit from additional days of pain control. If needed, the cost typically ranges from $12-30. These medications will only be dispensed if deemed necessary by the veterinarian.
I accept pain medications if needed.
I decline.


Extraction of Teeth (Dentals and Puppies/Kittens)
During dentals we may determine that a tooth has irreparable damage, or that the root is infected or exposed. In puppies or kittens, we often find baby teeth that should have fallen out but are still present (retained). Extraction of diseased or retained can be the best thing for a pet’s general health, the comfort of their mouth, and their breath. We only perform extractions if they are medically necessary, costs are $9-$35 per extraction.
I accept extractions if needed.
I decline extractions.


Vaccinations/Annuals

We require that all animals here for routine procedures be current on vaccinations. Juveniles and older animals are especially susceptible to those diseases for which we vaccinate, and the risk is higher with the stress of surgery.
Accept – Please update my pet’s boosters.
Decline - Please call me about the status of my pet’s vaccinations.


By clicking "Submit" you agree to the above terms in lieu of your signature. Please remember to call to schedule your pet's surgical procedure if you have not done so already.