Anesthesia Authorization
Your Pet’s safety and comfort are very important to us here at Tri-County Mobile Veterinary Clinic. So
that we can help insure their health, all pets having surgery here must be examined by our doctor. This presurgical exam should be performed no more than 4 weeks prior to the surgery. The Pre-surgical exam is repeated
on the day of surgery at no charge. In addition to an examination, the pre-surgical exam also includes obtaining
blood samples for any testing needed prior to surgery as well as making sure your pet is current on preventative
immunizations that have been given by a licensed veterinarian.
Advances in anesthesia have made elective procedures safer, with a low rate of anesthetic complications.
In certain rare circumstances a condition may exist that is not evident on physical examination or pre-anesthetic
lab screening, which could result in an anesthetic complication. All patients undergoing anesthesia will be
monitored during and after anesthesia. Pain relief medication will be administered in hospital and dispensed for
use at home at the discretion of the doctor.
We recommend pre-anesthetic blood testing before surgery and intravenous fluids during surgery for all
pets. If your pet does not yet have microchip identification we encourage you to have this done while under
anesthesia. The recommended services are described below.
If you decline any of these recommendations please check the appropriate box:
*** Pre-Anesthetic Blood Screen. ($88.00)
This lab test is recommended for pets under 6 years old and evaluates those organ
systems most directly affecting the safety of anesthesia (the liver and kidneys), as
well as testing for clotting function, anemia and dehydration.
Annual Health Screen ($129.00)
This lab test is required for pets older than 6 years old and is a more comprehensive
diagnostic health check than the pre-anesthetic blood screen. It is recommended as
part of a yearly or twice yearly physical exam for pets over 6 years of age.
□ I decline any pre-anesthetic testing
***
Intravenous Perioperative Fluids ($74.00)
An intravenous catheter and fluids help maintain blood pressure, oxygen perfusion,
and assist the body in processing anesthetic medicines more efficiently. They also
provide immediate access to give medications in case of emergencies.
□ I decline intravenous perioperative fluids
***
Microchip Identification ($45.00)
□ I decline microchip identification for my pet.
***
Dental Sealants ($39.00)
□ I decline dental sealants for my pet
I understand that the doctors and staff of Tri-County Mobile Veterinary Clinic will use all reasonable
precaution against injury, escape, or death of my pet. I understand the nature of the procedure(s) and the
relative risks involved and will not hold the doctor and staff responsible under any circumstances. I authorize
Tri-County Mobile Veterinary Clinic to provide the following services:
PROCEDURE(S):
DATE:
PET’S NAME:
OWNER’S NAME:
OWNER/RESPONSIBLE AGENT SIGNATURE:
PHONE NUMBER WHERE YOU MAY BE REACHED TODAY:
Thank you! We look forward to taking excellent care of your pet! ~Dr.Lori & staff