Memorial Road Pet Hospital
PLEASE READ CAREFULLY BEFORE SIGNING: Date:_____________
Anesthesia Authorization:
<Animal> is being admitted today for _____________________. This procedure requires a general anesthetic. We will be performing pre-anesthetic testing in order to provide the best care possible. Before placing your pet under anesthesia a veterinarian will review your pet’s medical history and perform a physical examination, including diagnostic testing to identify any existing medical conditions that could complicate the procedure and put your pet at risk. While the physical exam is important, the picture of a pet’s physical condition is not complete without pre-anesthetic diagnostic testing. This testing can uncover internal health concerns that cannot be detected from the physical exam alone. Pre-anesthetic lab work will be run at the veterinarian’s discretion.
_____ I understand that the veterinarian will perform a pre-operative blood profile on
<animal> if they deem it necessary for this procedure.
Please take comfort in knowing that if the veterinarian feels that your pet is experiencing any pain they will administer pain medication at their discretion.
_____ I understand that the veterinarian will administer pain medication to my <animal> at his/her discretion.
Home Again Microchip:
“Home Again” is a microchip that is placed under the skin for identification should your pet get lost without a collar and tag. The cost of the microchip is $49.99 which includes your registration and first year of upgraded service through Home Again.
Would you like to protect <animal> with a microchip today?
Yes____________ No_____________.
The health and well being of <animal> is our greatest concern. Please note that we will do our best to remain within the estimate of cost quoted for today’s procedures but circumstances may make it necessary for us to administer additional medications or lengthen the surgery or anesthesia time. If such complications arise we will try to contact you at the number provided below.
I understand that there are risks and complications to administering sedation/anesthesia to <animal>. I understand that I am responsible for any expected or unexpected costs of treating <animal>.
Signature______________________________________Phone ____________________
(Owner or Authorized Agent)