CANINE PRE-ANESTHETIC CONSENT FORM
Please read carefully and sign.
Like you, our greatest concern 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 full physical examination. However, we
also recommend performing a pre-anesthetic blood profile so that we can maximize the patient's safety. This
will alert the doctor of any abnormal chemistry values, such as dehydration, kidney disease, liver disease, or
diabetes. The presence of any of these conditions could complicate the procedure. These conditions may not
be detected unless a pre-anesthetic profile is performed. Additionally, the results of the profile may be used
later to develop faster, more accurate diagnoses and/or treatments in the future. State-of-the-art equipment
allows us to perform these pre-anesthetic blood profiles within the clinic, and we are committed to making this
technology available to your pet.
PRE-ANESTHETIC BLOOD PROFILE
Includes: 10 blood chemistries, electrolytes, and complete blood count.
Please complete the pre-anesthetic blood profile prior to surgery on my pet.
COST $69.00
Signature of Owner
HEARTWORM TEST
Heartworm disease is both very common and very serious. We therefore recommend that all animals
be tested yearly. Although this is not a required procedure, it is highly recommended by the
veterinarians.
Please complete a heartworm test prior to surgery on my pet.
COST $30.00
Signature of Owner
REFUSAL OF BLOODWORK
I have elected to refuse the recommended bloodwork at this time and request that you
proceed with anesthesia. I assume full financial responsibility for this/ these animal(s). I understand
that there is always a potential risk when using anesthesia or performing surgery.
Signature of Owner
CANINE PRE-ANESTHETIC ADDITIONAL FORM
PAIN MEDICATIONS
I would like for my pet to have pre-op pain medication for pain relief.
COST $14.00
I would like for my pet to have a post-op pain injection that lasts for 24 hours.
COST $15 - 30.00
I would like for my pet to have post-op, take-home pain medication for pain relief.
COST $10 – 25.00
I would like for my pet to have therapy laser treatment.*
COST $12.00
*Laser therapy treatment has been scientifically proven to be successful in
treating post-surgical pain. Laser therapy reduces pain and inflammation and
increases the rate of healing.
ADDITIONAL OPTIONS
I would like for my pet to have Sevoflurane, the safest gas anesthesia available to veterinarians.
COST $30.00
I would like for my pet to have an IV catheter and fluids during his/ her surgical procedure.*
COST $38.00
*Fluids during anesthesia will reduce the risk of low blood pressure. The
placement of a catheter also helps us quickly administer life-saving drugs in case
of an emergency.
I would like for my pet to have a Home Again Microchip.
COST $46.00