Owner____________________
2202 N. Gordon Street.
Alvin, TX 77511
Patient____________________
Date _____________________
Authorization for and consent to anesthesia and surgery or diagnostic/therapeutic
procedures, I hereby authorize the following procedure(s) to be performed:
_______________________________________________________
by the admitting veterinarian, or designated associates and assistants.
Unfortunately, there is no way to screen for or prevent all possible complications.
Statistically 5% of all routine surgeries on healthy pets have some type of complication.
Less than 1% of the time, these complications can result in the death of the patient. Due
to the fact that time is critical in these situations we may not be able to contact you before
initializing treatment. By consenting to this procedure you are agreeing not to hold Alvin
Animal Clinic, Dr. Hoffpauir, Dr. West or any other member of the Alvin Animal Clinic
staff liable for unforeseen complication of the procedure. Due to the unpredictable nature
of these complications we take every preventative measure that we can including
mandatory EKG, Blood Pressure, Oxygen Level Monitoring and Intravenous Catheter
and Fluids with every procedure. All patients will also receive laser treatment at the
incision site(s) that will promote healing and reduce swelling and inflammation, which
will allow the patient to have a much smoother and faster recovery. You are also agreeing
that you will be responsible for any cost incurred as a result of treating any potential
complications. Payment is due at the time services are rendered, even if the unfortunate
event that the patient does not survive the procedure.
[ ] YES. I want to have an optional pre-anesthetic blood screen performed.
Cost: $153.00 Note: Pre-Surgical Blood Screening is Mandatory for all patients 7 years
or older. Some non-elective procedures may include a mandatory blood profile
[ ] NO. I do not want to have a pre-anesthetic blood screen performed.
Please accept or decline the pre-anesthetic blood screen by initialing.
Would you like us to trim your pet’s toe nails while under anesthesia?
[ ] YES ( no charge)
[ ] NO Do not cut my pet's toe nails
Please accept or decline the nail trim at no charge by initialing.
Would you like us to place a microchip to provide permanent identification for your pet?
This cost includes the price for the microchip, to have it implanted and for your
registration fee.
[ ] YES Cost $52.23
[ ] NO
Please accept or decline the placement of a Microchip by initialing.
An injection of pain medications is give at the time of surgery for all patient unless they
are already on pain medications. Would you like additional pain medications to go home
with your pet after surgery?
[ ] YES Cost $30.00 to $45.00 depending on the size of your pet
[ ] NO
Please accept of decline pain medications to go home with your pet by initialing.
Some of our patients can experience itching at the site of the incison, which can cause
them to lick or chew. Doing this can cause them to open up the incision. This can be
prevented with an E-Collar which prevents them from being able to reach their incision.
Would you like your pet to be sized and sent home with an E-Collar after Surgery.
[ ] YES Cost may vary from $12.00 to $30.00 depending on the size of your pet.
[ ] NO
Please accept of decline an e-collar to go home with your pet by initialing.
Signature ___________________________________________
Date _______________________________________________
I understand that my pet will be checked for fleas upon arriving at the clinic. If fleas are
found, a treatment will be applied to my pet and I will be responsible for the cost. This is
for the health of my pet and the protection of all the other animals in the hospital.
Initials of owner _____________
WHAT IS THE BEST PHONE # YOU CAN BE REACHED AT TODAY?
________________________________________________________________________
OFFICE USE ONLY
Patient Name ______________ Chart #_____________ Date______________
Anesthesia start time: _________________ Anesthesia end time: ______________
Surgery start time: __________________ Surgery end time: _________________
Technician: ____________ Surgeon: _________________
Charges:
This pet is also boarding and needs the sx. Boarding discount applied ______
Anesthesia inj :
Drug
- Ketamine (Ketaset)
- Medetomedine (dexdormitor)
- Atipamezol (antesedan)
- Butorphanol
- Propofol
Amount
_______
_______
_______
_______
_______
Route
_____
_____
_____
_____
IV
Pain Control:
Drug
- Metacam inj
Amount
_______
Route
_____
Medications to go home:
Drug
mg
Route
Frequency
_______________ ______ ________
______
__________ ___________
_______________ ______ ________
______
__________ ___________
Call Back in ________ Days
Re-check in _________ Days
amount
Duration