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Memorial Road Pet Hospital
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?
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)
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