Pre-Anesthetic/Pre-Surgical Diagnostic Waiver & Anesthesia Authorization

Downloadable Form –> Pre-Anesthetic and Surgial Waiver

Pre-Anesthetic/Pre-Surgical Diagnostic Waiver & Anesthesia Authorization

Our doctors use the safest anesthetic and surgical protocols available to minimize risk to our patients. No anesthetic or surgical procedure, however, is without risk, up to and including death. Although modern veterinary anesthetics are generally considered safe, problems can still potentially occur. We offer a pre-anesthetic blood profile be done prior to administering anesthesia. The importance of these tests is that they help identify patients for whom anesthesia may pose the greatest risk. If your animal is considered a high-risk patient, our veterinarians may deem it necessary. However, pre-anesthetic bloodwork is optional. I fully understand the nature of the procedures to be performed and the potential risks involved. I further acknowledge that no guarantee regarding the outcome of any procedures has been expressed or implied by Mulvane Animal Clinic or its agents. I accept full financial responsibility for all services rendered. This may include any charges which arise due to unforeseen treatments needed for the safety and comfort of or any medical or surgical complications incurred.

Client's Name
First Last
Pet's Name
I understand the risks of both anesthesia and surgery, and I DO/DO NOT WANT A PRE-ANESTHETIC BLOOD TEST for this procedure
- Do
- Do Not
If you DO want pre-anesthetic bloodwork done, please indicate which option you prefer below:
- Pre-Surgical Blood Panel ($50)
- Complete Blood Panel ($115)
With any surgical procedure, a certain degree of pain/inflammation is to be expected. If the attending veterinarian deems analgesic prophylaxis necessary, an injectable pain medication may be given at an additional cost of $25 for cats, $25 for dogs under 40 pounds, $45 for dogs 41 to 70 pounds, and $55 for dogs greater than 71 pounds.
- Yes
- No
Please input the surgery that you have scheduled
I have read and understand the above information. I authorize the use of anesthesia for this procedure:
Date
Date Format: MM slash DD slash YYYY