Pre-Anesthetic Evaluation & Anesthesia Authorization
Our greatest concern is the well being of your pet. Today, your pet will undergo general anesthesia or tranquilization. It is important that
your pet has not eaten food this morning, decreasing the chance of vomiting after anesthesia. Our doctors use a combination of injectable and/or gas
anesthetic agents dosed for each individual patient. A full physical examination is performed before putting your pet under anesthesia. However,
many conditions of the liver, kidneys, pancreas, blood, and/or cardiovascular abnormalities are not detected unless diagnostic testing is performed.
Anesthesia is carefully administered and each patient is closely monitored.
Prior to anesthesia, our Doctors at Veterinary Medical & Surgical Hospital recommend an EKG, Blood Pressure Analysis, and diagnostic
testing consisting of a Complete Blood Count, Urinalysis, and/or Blood Chemistry Analysis. These tests evaluate kidney function, liver function,
glucose levels, white & red blood cell level, serum protein level, electrolytes, cardiac function, and cardiovascular status and allow our doctors to
tailor anesthesia to your pet’s specific needs. Our doctors reserve the right to perform any necessary testing if your pet’s Physical Status
Classification is greater than I, pending a verbal consent from the owner(s).
Our laboratory is fully equipped and staffed to perform these tests.
Lab results are immediately available before your pet’s anesthesia.
Please initial one or more of the following choices:
Yes, Please perform a Pre-Anesthetic Blood Pressure
Analysis to assess my pet’s cardiovascular status ($24.98).
No, I decline a Pre-Anesthetic Blood Pressure Analysis for my
pet.
Yes, Please perform a Pre-Anesthetic EKG to aid detection
of heart arrhythmias in my pet ($24.98).
No, I decline a Pre-Anesthetic EKG for my pet.
Please initial one of the following choices:
Yes, Please perform a Pre-Anesthetic Basic Health Profile
which includes a Complete Blood Count and Urinalysis to assess my
pet’s red and white blood cell count and kidney function ($73.47).
This test is recommended for healthy pets less than 3 years old.
Yes, Please perform a Pre-Anesthetic Routine Health Profile
which includes a Complete Blood Count, Urinalysis, and an
abbreviated Blood Chemistry Analysis to check my pet’s major organ
functions ($149.95). This test is recommended for healthy pets 3-7
years of age.
Yes, Please perform a Pre-Anesthetic Complete Health
Profile which includes a Complete Blood Count, Urinalysis, and an
expanded Blood Chemistry Analysis to assess my pet’s major organ
functions ($199.95). This test is recommended for pets over 7 years
of age or with a Physical Status Classification of greater than I.
No, I decline Pre-Anesthetic blood testing for my pet.
Physical Status Scale as Defined by the American Society of Anesthesiologists
Grade I
Grade II
Grade III
Grade IV
Grade V
Normal and admitted for elective surgery.
Animal with slight to moderate systemic disturbance.
Animal with major systemic disturbance that limits activity but is not incapacitating.
Animal with very severe systemic disturbance that could lead to death if surgical or medical intervention is not applied.
Animal in a moribund state that will probably die despite surgical or medical intervention.
The nature of the anesthesia and procedure to be performed on my pet has been adequately described to me. I give written permission to perform these
procedures. I understand there is no possible way to foresee or guarantee a possible outcome of any procedure. I agree to pay for all service rendered.
Under no circumstances do the doctors at VMSH claim any board certification status.
Authorization for Administration of Pain Medication
Authorization for Emergency Medical Treatment
Pain management for your pet’s procedure includes one strong morphinelike injection and a powerful NSAID injection giving up to 12 hours of
pain relief. This combination of injections speeds recovery and relieves
postoperative suffering from surgeries such as spays, neuters, declaws,
and dental procedures. To ensure that your pet is as comfortable as
possible, our doctors recommend that any pet undergoing a surgical
procedure have a prescription for home pain relief.
If, in the event of an unforeseen medical emergency, my pet
experiences cardiac or respiratory arrest
____Yes, Please prescribe an additional 5-day prescription for home
pain relief. ($38.97)
____No, Do not prescribe pain medication for my pet.
___ Yes, Please perform CPR and/or all means of resuscitation
to revive my pet.
___ No, Please Do Not Resuscitate my pet.
Time of last meal:
Current medications:
Allergies:
Pet’s Name:____________________________________________________
Procedure(s) to be performed:
Special Instructions:
Owner’s Signature________________________________
Owner Name (print) :_______________________ Date: ______________
________
Daytime Phone Number _______________________________