Client's Name *

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Patient's Name *

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Procedure *

Date

Consent

Please read carefully before you sign:

Your pet may require anesthesia for the above elected procedure. We recommend a blood profile to assess and minimize the risk of anesthesia for your pet and check your pet's health. The latest technology enables us to run safe, and accurate blood chemistries, minutes before anesthetic induction. These tests are similar to those your physician would run if you were undergoing anesthesia. Results will also serve as future reference values should your pet become ill.

CBC (Complete Blood Count) - $50

Accept

Assesses anemia, infection, and clotting

Pet Health Screen 1 (Pre-Anesthetic Chem Profile) - $86

Accept

Recommended for healthy pets younger than 6 years. Evaluates: kidneys, liver, hydration status and sugar levels.

Pet Health Screen 2 (Comprehensive Diagnostic Profile) - $129.50

Accept

Recommended for healthy patients 6+ years. Evaluates: kidneys, liver, hydration status, sugar levels, cholesterol, certain cancers, pancreas.

Electrolytes - $32.00

Accept

Recommended to run with other profiles for a complete health evaluation. Evaluates: hydration, metabolic disorders, and conditions such as Cushing's or Addison's disease.

I DECLINE blood work tests

I am declining the recommended pre-anesthetic blood profile and request that you proceed with anesthesia.

Other services desired while patient is sedated/anesthetized:

Check all that apply:

Post-Operative Pain Management *
Sub-Q Fluid Replacement (aids in quicker recovery) - $30
Sanitary clip of rectum/genitals ($24.90)
Microchip ($33)
Canine Heartworm Test ($29)
Canine E.Canis/Lyme/Anaplas/Heartworm Test ($55.50)
Feline Leukemia/FIV Test - $56
Feline Clip and Brush Out Mats - $40

Please select Vaccinations below:

Authorization and Risk Assessment

I authorize anesthesia/surgery for my pet. The nature and risks of this procedure(s) have been explained to me. I understand that some risks always exist with anesthesia and/or surgery, and I am encouraged to discuss any concerns I have about those risks with my veterinarian before the procedures(s) are initiated. My signature on this consent form indicates that any questions have been answered to my satisfaction.

I authorize Cobb Veterinary Clinic, P.C. to perform any additional diagnostic, treatment or surgical procedure(s) deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. While Cobb Veterinary Clinic, P.C. provides the highest quality of anesthesia monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures.

I fully understand these risks and understand that the veterinarians and hospital staff will try to minimize such risks. I will not hold Cobb Veterinary Clinic, P.C., the veterinarians, or any staff member liable for any complications that may arise.

BY SIGNING THIS FORM, YOU AUTHORIZE US TO PROCEED WITH DIAGNOSTICS AND TREATMENT UP TO

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Multiple Choice *

I AUTHORIZE the treatment up to $__________ before the doctor speaks with me and can give me an updated estimate of care.
I DO NOT authorize immediate treatment for my pet and wish to speak to the doctor before care is given.

I AUTHORIZE the treatment up to $__________ before the doctor speaks with me and can give me an updated estimate of care. *

You may request an itemized estimate if desired. This estimate may not be the actual amount of the total charge in the event of complications or if additional treatment is required. A deposit of $____________ is required and the balance of the fee for services rendered shall be due and payable upon completion of the case. *

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I HAVE READ AND FULLY UNDERSTAND THIS SURGERY AND ANESTHESIA CONSENT FORM.

Primary Contact Number *

Secondary Contact Number

Surgery & Anesthesia Consent Form