Authorization for Anesthetics

REQUIRED FIELDS [*]

Entering your full name will become your digital signature: [*]

Enter your pet's name: [*]

Enter your email: [*]

Procedure to be performed: [*]

Today's date:

There is always a risk when performing anesthesia on any animal; however, complications during and following anesthesia and surgical procedures can possible 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 of these and other ailments may affect surgical results and outcome, 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 $97.69, The cost of the profile is NOT INCLUDED in fee quoted for your pet's surgery.

SELECT ONE:

Yes, complete the blood work for my pet.
No, do not complete the blood work for my pet. I accept full responsibility for my choice.

Enter your phone number: [*]

Growth Removal patients only: If you would like to send the growth to the lab to check for abnormalities, it will be an additional $135.00 for one growth, plus $26.01 for each additional growth.

SELECT ONE:

Yes, please send off the growth to the lab
No, I would not like the growth sent off

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

By clicking "SUBMIT" I authorize and direct the veterinarians associated with Ark Animal Hospital to administer appropriate anesthesia, perform the above stated procedures and/or to do any other therapeutic procedures that their judgement may dictate to be advisable for the patient's well being. I understand the risk and nature of the operation and/or procedures to direct the veterinarians to provide such additional services for the patients they may deem reasonable and necessary including, but not limited to, the performance of or the arrangement for the performance of histopathology services and the provision of radiology services.

Because ALL ANESTHESIA AND SURGERY INVOLVES RISK, I further agree that the doctors and staff of Ark Animal Hospital shall not he held responsible in the event of disability or death associated with the performance of any of the aforementioned procedures.