ANIMAL MEDICAL CENTER, LLC
PRE-ANESTHETIC BLOOD TESTING CONSENT FORM
Client
Patient
Age
Date
Our greatest concern at AMC is the well being of your pet. Your pet is scheduled for anesthesia and/or surgery.
Before putting your pet under anesthesia, we will perform a physical examination. We also recommend that a
pre-anesthetic blood profile be performed to maximize patient safety and alert the doctor of any dehydration,
anemia, kidney or liver diseases, which could complicated the procedure. These conditions may not be detected
without a pre-anesthetic profile. These tests are similar to those your own physician would perform if you were
to undergo anesthesia.
(Save this Life Microchip with lifetime registration) Cost: $62.74
Bloodwork Choice #1
(201) Cost: $57.23
Includes: Complete Blood Count (Anemia, Infection, Clotting), BUN (Kidney Test), ALT (Liver Test)
(optional)
include (247) Electrolyte Panel
Cost: $19.48
Bloodwork Choice #2
(229) Cost: $97.34
Includes: Complete Blood Count (Anemia, Infection, Clotting), BUN & Crea (Kidney Tests), ALT &
ALKP (Liver Tests), Glucose (Sugar), Total Protein (Hydration), and electrolyte panel
Bloodwork Choice #3
(202) Cost: $137.45
Includes: Complete Blood Count (Anemia, Infection, Clotting), BUN, Crea, Phos (Kidney Tests),
ALT, ALKP & Total Billiruben (Liver Tests), Glucose (Sugar), Total Protein (Hydration), Amylase
(Pancreas test), Calcium (Tumors), Cholesterol, Albumin (Protein), and electrolyte panel
Please place a check next to the appropriate blood test that you wish for us to perform
Signature
I have elected to REFUSE the recommended blood test at this time and request that you proceed with
anesthesia. I understand there are potential risks when using anesthesia or operating on an animal. I assume full
financial responsibility for this animal.
Signature
I would like to have take-home pain medication for my pet. Cost varies according to size and weight.
Yes
No
Telephone number that I can be reached at today