Sedation & Anesthesia Authorization

Client's Name *

First

Last

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Patient Name (first/last): *

First

Last

On heartworm prevention? If yes, list product and last date given. If not, please type N/A *

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Chronic/current illness: If yes, list. If not, please type N/A *

Current medications, OTC, Herbal Supplements: If yes, list. If not, please type N/A *

You believe your pet is currently healthy enough to be sedated: *

Allergies to vaccines/medications: If yes, list. If not, please type N/A *

Dietary Restrictions/ Type of Food: *

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Heartworm Check – $50.00 (test checks: heartworm disease, Lyme disease, Ehrlichiosis, Anaplasmosis) *Required for canines prior to anesthesia. (a negative test within 1 year and current on monthly heartworm prevention *

Needs heartworm test
Does not need heartworm test

Select one bloodwork panel

Super Chem/ CBC – $132.00 (Chemistry (assess organ function) Complete Blood Count (assess anemia, infection, adequate platelets for clotting) **Required over 7 years old. Cost: $124.00

Mini Chem/ CBC – $111.00 (Chemistry (assess organ function) Complete Blood Count (assess anemia, infection, adequate platelets for clotting.) **Required under 7 years old Cost: $101.00

Please Choose One *

Yes – to Super Chem/ CBC $132.00
Yes – to Mini Chem/ CBC $111.00

Bloodwork Not Needed With DVM Permission (only applicable grooms & feline neuter) Bloodwork Completed: Date:

Feline Leukemia, Feline Immunodeficiency Virus Test – $55.00 *Recommended for felines at least once in their life or if in a high-risk category – at doctor discretion. (Spends time outdoors, around other cats, has been ill, been attacked by other cats) *

Needs FelV/FIV test
Does not need FelV/FIV test

Intravenous Catheter and Fluid Therapy : Cost – $24.20 – $59.00 IV Catheter placement ensures venous access to safely administer medications and fluid therapy for supportive care and in emergency situations. Your pet may have a shaved area on their front leg to allow placement.

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Home Again Microchip: Cost – $60.00 (including registration) Pet identification system involves injecting a small microchip – about the size of a grain of rice – under the skin between the shoulder blades of a dog or cat. Each chip has a unique code that when registered will allow pet shelters and clinics to use a scanner to identify your pet. *

Yes, Microchip my pet
No, Do not microchip my pet
Already Microchipped

List Other Services Authorized Today

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Have you withheld food? *

List last time food was given and water was given: *

Please read carefully, complete, initial and sign. Your pet is scheduled for an anesthetic procedure. Anesthetic agents are filtered through the liver and kidneys so it is important to know prior to anesthesia that the organs are functioning correctly. Thorough blood profiles help to verify that your pet is in a low-risk category prior to anesthesia and will help us adjust the pets’ anesthetic protocol as needed. The latest technology has enabled us to run safe and accurate blood chemistries minutes before anesthetic induction. These tests are similar to those your own physician would run when you undergo anesthesia. In addition, the results of these tests will serve as reference values for future use, should your pet become ill. Our veterinarians recommend bloodwork for all pets undergoing sedation and anesthesia.

I hereby authorize and direct the veterinarians of Petsburgh Pet Care to perform the procedures discussed and deemed advisable or necessary for my pet. The nature of the procedure has been explained to me and no guarantee has been made as to the results or cure.

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The services listed above may or may not be in addition to the procedure. If you have any questions regarding your estimate or if you need an estimate provided, please discuss it with the veterinary team prior to dropping off. Estimate needed: *

Yes, Estimate needed
No, Estimate not needed
Already received an estimate

I understand if abnormalities are found on bloodwork, additional lab work may be run as the veterinarian deems necessary to further assess the health status of my pet. *

I agree to additional bloodwork if needed
I disagree with additional bloodwork if needed

We believe controlling our patients’ pain is important. For that reason, we will administer medication before, during, and/or after your pet’s medical procedure to control pain, reduce discomfort and promote recovery. If indicated, additional pain relief medication will be administered with a corresponding charge.

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I authorize the use of appropriate sedation, anesthesia and medication as directed by the veterinarian, knowing there may be side effects associated with any medication. *

I authorize the use of appropriate sedation, anesthesia and medications.
I do NOT authorize the use of appropriate sedation, anesthesia and medications.

Should unexpected life-saving emergency care (CPR) be required and the hospital staff is unable to reach me, the staff does/does not have permission to provide such treatment and I agree to pay for such services. *

The staff DOES have my permission to provide life-saving emergency care.
The staff does NOT have my permission to provide life-saving emergency care.

I understand there is always a potential risk for sedation, anesthesia, surgery, even in apparently healthy animals, and I am encouraged to discuss concerns before the procedure begins. *

I understand there is always a potential risk for sedation, anesthesia and surgery
I do NOT understand there is always a potential risk for sedation, anesthesia and surgery.

I assume full financial responsibility for this animal and understand payments will be finalized prior to discharge. *

I assume full financial responsibility
I disagree – I do NOT assume full financial responsibility

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Signature of Owner *

Emergency Contact Number *

Date: *

May we text you when your pet is awake? If yes, please leave text #:

We will call you when your pet is ready to go home and to discuss at home care.

Sedation & Anesthesia Authorization

Select one bloodwork panel

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