Animal Kingdom Veterinary Hospital Anesthesia/Surgical Consent Pet’s Name

animal kingdom veterinary hospital anesthesia/surgical consent =========================== pet’s name: ______________________________

Animal Kingdom Veterinary Hospital
Anesthesia/Surgical Consent
===========================
Pet’s Name: __________________________________ Today’s Date:
______________
Owner’s Name: _______________________________________________________
Procedure: ___________________________________________________________
Medications: ___________________________________ Last Given:
_____________
Time of Last Food: _______________ Any signs of Illness: □Y □N
Symptoms: __________________
Contact Name: ____________________________ Phone:
________________________Texting ok?_____
Number where you can be reached AT ALL TIMES
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By signing below, you understand that anesthesia is not without risk.
To maximize the safety and well-being of your pet, please review the
following information.
Prior to placing your pet under anesthesia:
Pets under 6 years of age:
Dr. Highsmith strongly recommends a Pre-Anesthesia Screening to check
the liver and kidney functions as well as your pet’s blood clotting
time. Cost is $32.00.
□Accept □Decline Signature _____________________________________
Pets 6 years and older:
Dr. Highsmith strongly recommends the Senior Wellness Panel prior to
anesthesia. Otherwise, a Pre-Anesthesia
Screening is REQUIRED. Cost is $32.00. Signature__________________________________
Pain Management Package: This includes an injection of
anti-inflammatory pain medication prior to surgery and four days worth
of medication for after surgery. Cost is $32 to $48 depending on pet
size.
Please initial: Accept ________ Decline ________
FEMALE PATIENTS: If your pet is pregnant, would you like us to proceed
with spaying? Initial Yes____ No____ (The entire cost of the surgery
will be charged if NO is selected and pregnancy is not apparent until
the incision is made and the uterus is examined. In this event, the
incision will be closed with the uterus intact.)
Microchip implantation is available for permanent identification of
your pet for a fee of $44.00, which also includes the registration.
Would you like this done today? Initial Yes_____ No_____
E collar: would you like your pet sent home with an E collar to
prevent licking/chewing of the incision Yes__ No__
For an additional fee, I would like my pet to receive these services:
□Nail Trim □Ear Cleaning □Hygiene Trim □Express Anal Glands □Extract
baby teeth (must be done under anesthesia) □Other _______________
I accept financial responsibility for the above services to be
performed as well as any other procedures deemed necessary for the
well-being of my pet’s treatment. Non-emergency procedures will be
authorized by phone prior to performing the service. I understand that
my pet must be current on all vaccinations, and free of fleas and
ticks prior to or during his/her hospitalization. If necessary,
vaccinations, exams, and/or flea and tick treatment will be given, and
I am financially responsible. I understand I may request an estimate
of services. Failure to receive an estimate does not release my
financial responsibility for services rendered. I understand the
following are the most common post-operative complications: incisional
infection, and sutures pulling out, resulting in the incision opening.
Any complications may require treatment at an additional expense.
__________________________________________
_______________________________
Signature Date