Emerson Animal Hospital
419 Lake Air Drive, Waco, Texas
76710
(254) 772-3520
Anesthesia/Surgery/Dental Consent
Form
Date_____________________________
Client Name:
____________________________________________________
Address:________________________________________________________
________________________________________________________________
Telephone
Numbers (please include area code):
Home:(____)_____-______________
Work:(____)_____-_____________
Cell:(____)_____-______________
Pager:(____)_____-_____________
Pet
Name:____________________
Species:______________________
Breed:________________________
Sex:_________________________
Color:________________________
Birth Date or Age:______________
Your pet will be
undergoing general anesthesia plus a surgical/dental procedure
today. In order to recognize any underlying abnormalities
present, we require a pre-surgical blood profile to be
run prior to anesthesia to determine blood glucose
levels and internal organ function. These blood tests help us
assess the health status of your pet more completely and determine
if there are any additional precautions necessary before
surgery. A general profile is required for
geriatric animals (over 7 years) but is the most thorough for any
pet. There is an increased risk with advancing
age. Should a problem be detected, the procedure will be
postponed and the condition treated.
There is an
additional charge for these blood tests. We hope you
understand the need for these important tests.
Pre-anesthetic
profiles are recommended and run to insure the safety of your
pet!
( ) For my
pet's safety, do the general profile.
Pets seven years of
age and older must have a general profile prior to
anesthesia and surgery because of their age and the possibility
of age related physiological changes which
may affect their ability to safely undergo
anesthesia.
( ) I
prefer the modified profile.
If this pet is a
dog, is he/she on Heartworm preventative? Yes
No
If yes, what kind?
____________________________________________
If not,
we must do a heartworm test. We do not give
anesthetics to heartworm positive pets for safety reasons.
Heartworms compromise the function of an animal's heart and lungs,
often severely, and can cause
death.
I authorize the
following surgical procedures:
______________________________________________________________
Many pets also have
dental problems that may be treated and corrected at the time of
anesthesia for another procedure. Combining a surgery with
dentistry prevents the need for another anesthetic and is safe for
your pet. Relieving the pain and infection associated with
dental and gum disease is a major priority for each of our
patients.
I authorize a
dental if my pet's teeth need cleaning.
Yes No
If additional
dentistry, such as extracting teeth or filling cavities, is
required, these procedures are done at an additional charge.
After assessing the dental needs of your pet, we will contact
you with an estimate should other work be necessary.
Because of the pain
associated with surgery and dentistry, we will give an
injection to provide relief of that pain during or
after these procedures.
Pet loss through
theft or escape from home or car is a very real, frequent and
traumatizing occurrence. Should this happen, how could you
and your pet be reunited? Implantation of an identification
chip beneath your pet’s skin in the area of his/her shoulders is
the most reliable method of recovery today.
I would like a Home
Again Identification Chip for my pet! ( ) Yes ( ) No
Would you like us
to:
( ) Contact
you at ( ) work or ( ) home.
( ) Go ahead
with whatever is needed.
( ) Halt
procedure.
The nature of such
service has been described to me to my satisfaction and I
realize that no guarantee nor warranty can ethically or
professionally be made regarding the results or cure.
PROFESSIONAL FEES ARE TO BE PAID AT THE
TIME SERVICES ARE PERFORMED
How will you be making payment
today? Sorry, we do not
charge!
Cash ___ Check ___ Visa ___ M/C ___ Discover ___ American Ex.
___
* In admitting my
pet(s) for diagnostics, treatment, or surgery, I authorize the
veterinarians of Emerson Animal Hospital, and their support staff,
to administer such treatment and/or perform such diagnostic or
surgical procedures as deemed necessary.
* No guarantee or
assurance can be made as to the results that may be
obtained.
* Further, I
understand that a deposit of 50% is required before services are
performed and I assume full financial responsibility for all
charges incurred by my pet. I realize that these charges may
exceed a given estimate if complications arise. I understand
that I will be contacted prior to treatment, if
possible, should complications occur.
* I understand
that I am personally financially responsible for all
services rendered by the doctors and staff of Emerson Animal
Hospital and that payment is due on the date of the
anesthesia/surgery/dentistry.
Signature:
________________________
Signature:________________________
* Issuers of bad
checks and persons attempting theft of services will be prosecuted
to the full extent of the law
