DROP OFF • SURGICAL CONSENT • DENTAL FORM • PRESCRIPTION REFILL

PRE-ANESTHESIA CONSENT

Please fill out the form below as completely as possible. If you have any questions, please call us at 618.222.9860.

You may also dowload the form here and bring it with you.

Client and Patient Information:

Your Name:

Your Pet's Name:

Procedure:

Date of Procedure:

Best Friends Animal Hospital always has the safety & comfort of our patients as the highest priority. When our pets undergo anesthetic procedures, complications can arise. To limit the risks of anesthesia to your pet, we will perform a complete physical exam, place an intravenous catheter prior to their procedure (exceptions can occur for aggressive animals), use high-tech vital sign monitoring, tailor our pain control to the needs of the individual, & your pet will recover in our intensive care unit (ICU). During the physical exam we will look at all body systems but specifically, we are looking for things that could place your pet at higher risks during anesthesia. The catheter will allow the doctor to administer anesthetic drugs, fluids or emergency medications, should they be needed. Vital sign monitoring can help us detect problems early, which is when they are most easily corrected. In our ICU, we will monitor your pet until he/she has fully recovered. This greatly enhances the safety of recovery, but also allows us to adjust pain medications so each patient gets individualized pain control.

Despite our best efforts, risk factors can be present that we cannot detect without additional testing. We recommend that all patients undergoing anesthesia receive screening for problems that cannot be detected during the physical exam. The screening tests include lab work and an EKG for all patients. The lab work recommended is more extensive as patients get older, or for those having preexisting health conditions. An EKG will look for signs of an irregular heart rhythm. The lab work consists of blood work to look for kidney or liver problems, anemia, low protein, blood sugar, and more. Please check the appropriate box below, under the category that best describes your pet – young (<6yrs) & healthy, OR mature or with preexisting conditions:

	Young (<6yrs) & Healthy	Mature (>6yrs) or With Preexisting Conditions
Description of Screen	• PCV/TP • Abbreviated Blood Chemistry • Preanesthetic EKG	• Complete blood count • Complete chemistry panel • Urinalysis • Preanesthetic EKG
Cost	Package Price = $47.50	Package Price = $102.85
Authorization	Yes, I would like this screen. No, I decline & understand my pet could have conditions that place him/her at risk.	Yes, I would like this screen. I decline this screen, but would like the Young & Healthy version. No, I decline & understand my pet could have conditions that place him/her at risk.

Please check the box for any additional procedures you would like performed today. If you are not familiar with any procedure listed, please ask our team to clarify for you.

Microchip Placement ($31.50)

Dental Cleaning & Polishing (price dep on size of pet)

Ear Cleaning ($8.95)

JPS Screen X-ray ($52.00)

I would like to have a complimentary nail trim on my pet today. Yes No

I understand that if my pet is found to have fleas that Best Friends Animal Hospital will treat my pet and I will be charged accordingly.

Contact Information: Where Can We Reach You TODAY?

Phone:

Alternate Phone:

Emergency Contact (if you cannot be reached):

Name:

Relationship to Owner:

Phone:

Alternate Phone:

If I cannot be reached, I authorize the above person to act on my behalf regarding the medical care my pet should receive. I understand I will assume full and total financial responsibilities for any and all services rendered as a result of their decisions.

In Case Of An Emergency (Please choose only one):

1) I authorize the doctors and staff of Best Friends Animal Hospital and Pet Resort in an emergency situation to follow through with such procedures as are necessary for the well-being of my pet on a continuing basis regardless of the additional cost which I understand cannot be estimated or calculated at this time. I understand that I assume all financial responsibility for all services rendered and inventory utilized during this emergency procedure.

2)If an emergency situation develops and neither I or my emergency contact can be reached at the telephone numbers given, I authorize the doctors and staff of Best Friends Animal Hospital and Pet Resort to continue treatment but the emergency procedure cost should not exceed $ .
I understand that this cost is in addition to services in the original estimate for surgery/anesthesia.

I DECLINE any emergency treatment if complications develop before, during or after the anesthetic procedure.

As the owner or representative of the owner, I authorize the surgery/anesthetic procedures outlined in my estimate. I do hereby acknowledge that I understand that there are no guarantees either implied or expressed that the procedures authorized will be without complications from unexpected events beyond the veterinarians’ and hospital’s control.

I understand that I will be financially responsible for all charges incurred for this procedure(s) and that payment in full is due upon surgical release of the patient.

Signature

Date