" indicates required fields
DATE OF PROCEDURE
MM slash DD slash YYYY
EMERGENCY CONTACT NUMBER
LIST ALL PROCEDURES THAT ARE TO BE COMPLETED TODAY.
Has your pet ever:
HAD A SEIZURE?
BEEN DIAGNOSED WITH HEART DISEASE?
BEEN DIAGNOSED WITH KIDNEY DISEASE?
BEEN DIAGNOSED WITH LIVER DISEASE?
BEEN ON ANY LONG TERM MEDICATION?
HAS YOUR PET BEEN FASTED?
REQUIRED FOR ALL PETS OVER 6 YEARS OF AGE AND STRONGLY RECOMMENDED FOR PETS UNDER 6
As part of our commitment to offer the safest care for your pet, we will perform a physical examination prior to anesthesia. We strongly recommend that a pre-surgical blood screen be performed to determine if there is any underlying problems. Problems that might lead to complications during or after anesthesia and may not be evident on a physical examination.
PRE-OPERATIVE BLOODWORK : $81.46
I hearby authorize the use of such anesthesia as you deem advisable. I agree to indemnify and hold you harmless from and against any and all liability arising out of any of the procedures listed above.
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