General anesthesia has become safer in recent years with the advent of newer drugs and better patient monitoring. Every surgical patient will have an intravenous catheter placed, so that in the event of an emergency, life-saving drugs can be more rapidly administered. Intravenous fluids will be administered to control blood pressure, blood loss and speeds recovery.

PREANESTHETIC BLOODWORK:

To ensure your pet's safety during anesthesia, we recommend preanesthetic bloodwork that will assess organ function, clotting ability, detect anemia, or infection. (CBC plus platelet count, kidney, liver, diabetes screening, hydration status).

All patients over the age of 7 are at a greater risk for complications so it is imperative that we assess organ function with the basic presurgical panel. However, it is STRONGLY RECOMMENDED that we assess our thyroid and urine in patients 7 years and older with our comprehensive panel. *

I would like the recommended basic presurgical panel, CBC and mini chemistry - COST $101.00

I would like comprehensive presurgical bloodwork, CBC, full chemistry, T4 and U/A - COST $144.00

I accept the risks involved with sedation/anesthesia and choose not to do any presurgical testing.

THORACIC RADIOGRAPH: The chest x-ray is used to evaluate heart size and will try to rule out lung problems that may alter how gas anesthesia is given. If your pet is over 7 years of age it is recommended. The cost is $82.00 *

Request

Decline, I accept the risks involved with not doing a thoracic film

MICROCHIP: While under anesthesia, would you like us to place a microchip? The cost is $53.00 *

Request

Decline

Name of current medications given?

When was medication(s) last given?

Phone number(s) at which owner can be reached today or tomorrow *

If pain medication or antibiotics are necessary following the procedure. Which would you like? *

Tablets

Liquid

Would you like a text message after surgery? *

Yes

Number to Text

In the event that something unforseen should occur while your pet is under the care of Lincolnway Veterinary Clinic and life saving measures would need to be performed I: *

Would prefer that my pet pass without any sort of resuscitative measures taken.

Would like any life-saving procedures should the need arise be taken to the best of the doctors' ability until I can be contacted. Further I understand that I am financially responsible for all costs incurred during this process.

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. I give the staff at Lincolnway Veterinary Clinic permission to proceed with surgery and perform any life-saving procedures should the need arise (if designated above). Further, I understand that I am financially responsible for all costs incurred during this surgery. *

I understand

Lincolnway Veterinary Clinic will be returning any leashes or carriers to the owner at the time of dropping a patient off for a hospital stay. I understand that it is my responsibility to bring the appropriate items back to the clinic upon pickup of my pet. Furthermore, I understand that if I do not have the appropriate items to pick my pet up it will be my responsibility to obtain them or to purchase a leash or cardboard carrier directly from Lincolnway Veterinary Clinic. If I chose to carry my pet out of the clinic without a leash or carrier I understand that it is my responsibility to get my pet safely to my vehicle and I release Lincolnway Veterinary Clinic and its staff from all responsibility for my decision. *

I understand

I have read and fully understand the terms and conditions set forth above. *

I understand

I agree that my electronic signature is the legal equivalent to my manual signature on this agreement. *

I agree

Signature *