Procedure

Patient Name *

Age

Procedure for Fasted

Name *

First

Last

Date

Assistant to Call for Questions

Preferred Method of Contact

Call
Text
Email

Mid-Day Phone Number

Use Multimedia?

Yes
No

Fasted for past 12 hours?

Yes
No

Email *

Pre-Anesthetic Blood Testing and EKG

Like you, our greatest concern is the well-being of your pet. Before putting your pet under anesthesia, we will perform a pre-surgical examination. However, many conditions, including disorders of the liver, kidneys, heart, or blood, are not detected unless EKG and blood testing is performed. Such tests are especially important before any type of surgical procedure.

For these reasons, we highly recommend heart ($51.50) and blood ($108.75) screening and will perform these tests unless declined.

Our laboratory is fully equipped and staffed to perform these important heart and blood tests. Results will be immediately available to examine before anesthesia and/or surgery.

Pre-Anesthetic and EKG Screening Consent *

I accept pre-anesthetic blood screening for my pet.
I decline pre-anesthetic blood screening for my pet, and I accept liability in connection therewith. (If your pet is 6 years of age or older this test is required.)
I accept EKG screening for my pet.
I decline EKG screening for my pet, and I accept liability in connection therewith. (If your pet is 6 years of age or older this test is required.)

Additional Procedures

Please mark any additional procedures you would like performed while your pet is under anesthesia:

Additional Procedures *

If Other, please specify

Dentistry Information

Applicable to all animals undergoing a dental procedure: Our pets require sedation before a thorough evaluation of the mouth can be completed. While your pet is under anesthesia an x-ray of the mouth will be obtained to identify the presence of disease. The teeth will be completely cleaned, polished, and examined. The veterinarian will then extract any teeth that are loose, decaying or pose a future health risk for your pet. It is much safer and cost effective to complete all dental procedures during this initial visit rather than schedule another appointment with general anesthesia required. Please understand that we will only do what we deem necessary for the future health and well-being of your pet.

Dental X-ray *

I accept Full Mouth Dental X-rays canine ($226.50)
I decline Full Mouth Dental X-rays canine ($226.50)
I accept Full Mouth Dental X-rays feline ($143.50)
I decline Full Mouth Dental X-rays feline ($143.50)
I accept single view Dental X-ray of suspected diseased tooth ($38.00/view not to exceed price of Full Mouth)
I decline single view Dental X-ray of suspected diseased tooth ($38.00/view not to exceed price of Full Mouth)

Home Care

Dentacetic Wipes
CET
T/D
Toothbrush Kit

Owner Release

I understand that the veterinarians and staff will use all reasonable precautions against injury, escape, or death of my pet. I understand that all anesthesia involves some minimal risk to my pet, and I will not hold the veterinarian and/or staff responsible under any circumstances. I understand that I assume all risks.

Consent *

I have read all of the above information and agree.

Admit Form

Admit Form

Admit Form

Pre-Anesthetic Blood Testing and EKG

Additional Procedures

Dentistry Information

Owner Release

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