THE ANIMAL WELLNESS HOSPITAL OF HIGHLANDS
SURGICAL – ANESTHETIC CONSENT FORM
I <first-name> <last-name> - <number> being the owner or authorized agent for <animal>, do hereby
give my permission to sedate, anesthetize, and/or perform surgery on my animal as recommended by the
doctors or staff of The Animal Wellness Hospital.
SCHEDULED PROCEDURE: <date>__________________________________________
All patients will receive a thorough physical examination before anesthesia is administered. However,
many conditions, including disorders of the liver, kidneys, and blood cannot be detected through a
physical examination alone. Therefore, we strongly recommend that pre-anesthetic blood testing be
performed on your pet before anesthesia is administered. These tests also provide a baseline of normal
values that may be useful if your pet becomes ill at a later date.
Non-Elective Surgeries - An IV Catheter will be placed and intra-operative fluids administered.
Elective Surgeries - I approve / decline an IV Catheter/intra-operative fluids.
IV Catheter and Intra-Operative Fluids are required for every patient over the age of 7 yrs.
Pre-anesthetic Testing Options (Please check one of the following):
Bloodwork is required for every animal over the age of 7 yrs. If the animal has had bloodwork in
the past 3 months with no health problems it will be at the doctor’s discretion whether or not to
repeat bloodwork.
____1. BRIEF PREANESTHETIC BLOOD SCREEN checks for anemia,
kidney disease, liver disease, and an abnormal blood sugar. This is
recommended as a minimum for all patients undergoing anesthesia.
____2. STANDARD PREANESTHETIC BLOOD SCREEN checks for
anemia, protein, blood sugar, infection, kidney, and liver
problems. This is highly recommended for all animals undergoing
anesthesia. (SAP and CBC)
____3. ADVANCED PREANESTHETIC BLOOD SCREEN is highly
recommended by the Veterinarians for special procedures, high risk
or senior patients. (Complete Biochemical Profile, CBC,
Differential and X-Ray)
COST= $38
COST=$64
COST=$110
____4. I have elected to refuse the recommended pre-anesthetic bloodwork.
Pain Management:
 Post-op pain medication will be given at an additional cost, as needed, at the discretion of Doctor.
 Post operative home pain medication
Approved
Declined
LASER SURGERY, which decreases pain, bleeding and swelling is available for an additional $25.
Approved
Declined
I understand the risk of the above listed surgical procedures as well as the risk of anesthesia. I have read
the preceding information, agree to the indicated procedures, and agree to be fully responsible for the
costs that will be incurred.
_______________________________
SIGNATURE OF OWNER/AGENT
_____________
DATE
DISCHARGE TIME: _________________________________
____________________________
EMERGENCY NUMBER
ADMITTED BY: _________________________________