Anesthesia Form - Ark Animal Hospital

Forms

Authorization for Anesthetics Form

Fill Our Anesthetics Form Below

Authorization for Anesthetics

Name(Required)

First Last

Pet's Name:(Required)

Email(Required)

There is always a risk when performing anesthesia on any animal; however, complications during and following anesthesia and surgical procedures can possibly be avoided if the doctor is aware of any underlying illness. Ailments such as anemia, liver disorders, kidney malfunction, blood clotting disorders, and infections may not be evident upon physical examination. Because these and other ailments may affect surgical results and outcomes, we strongly recommend that all animals undergoing anesthetic and surgical procedures have a pre-anesthetic profile.

The profile consists of the following lab tests:

Blood Glucose
Complete Blood Count
Total Serum Protein Test
ALT - Liver Function
BUN - Kidney Test

*The cost for the profile is $115.00. The cost of the profile is NOT INCLUDED in the fee quoted for your pet's surgery.

SELECT ONE:(Required)

Yes, complete the blood work for my pet.

No, do not complete the bloodwork for my pet. I accept full responsibility for my choice.

IF abnormalities are found or if you need to reach me, please call this number.(Required)

Procedure to be performed:(Required)

***PAIN MEDICATION IS INCLUDED IN COST OF ALL SPAYS, NEUTERS, AND DECLAWS***

Date(Required)

Signature

Growth Removal Patients Only: If you would like to send the growth to the lab to be analyzed, it will be an additional $150.00 for one growth, plus $30.00 for each additional growth.

Yes, please send off the growth to the lab

No, I would not like the growth sent off

Signature

Bladder Stone patients only: If you would like to send stones to lab for analysis to help prevent reoccurrence.

SELECT ONE:

Yes, send stones for analysis @$45.00

No, do not send stones for analysis

Signature