Client Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Phone *

Email *

Pet's Name *

Breed *

Color *

Age/DOB *

Sex

Male
Neutered Male
Female
Spayed Female

I am the owner of the above-described animal. I hereby consent and authorize the performance of the following surgical procedure: *

IV fluids can help support patients during an anesthetic event. If recommended by the doctor, do you give consent to fluids? Cost is approximately $82

Yes
No

The following are suggestions for blood chemistry screening prior to anesthesia. Although we recommend these tests, they are not required unless specified by a doctor.

Animal under 6 years of age, apparently healthy. 6 chemistry screen to assess liver function (ALT, ALKP, TP), Kidney function (BUN, CREA) and blood sugar (GLU). Cost is $62.00
Animal over 6 years of age, or younger with health problems. Complete chemistry panel. In addition to the above tests, Calcium, Phosphorus, Cholesterol, Albumin and Amylase levels are tested. Cost is $90.00
Canine Heartworm and Tick-Borne Disease Test. This tests for heartworm disease as well as 3 tick borne disease including: Lyme, Anaplasmosis and Ehrlichia. Heartworm exams are recommended annually. Cost is $39.90 (Canine Only)
I prefer not to have any blood chemistry test performed.

Optional Add-on

Laser therapy – we offer red light laser therapy for incisions post-surgery. The laser not only helps speed the healing process but can also help reduce pain and inflammation. $29.40 (If applicable)

I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) beyond those set forth above. Therefore, I hereby consent to and authorize the performance of such procedures of operations as are necessary and desirable in the exercise of the veterinarian’s professional judgment.

I also authorize the use of appropriate anesthetics and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarian. I have been advised as to the nature of the procedures or operations and the risks involved. I realize that results cannot be guaranteed.

I have read and understand this authorization and consent.

Today's Date *

Signature of Owner or Agent *

Clear Signature

unless for and

Emergency Telephone Number *

Adapted from a form approved by the American Veterinary Medical Association 1982

Anesthetic Release FormEast Emporia Veterinary Clinic

Fill Out the Anesthetic Release Form

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