Anesthesia Release and Consent Form

Name: Apple Tree Animal Clinic
Price range: $

Complete our online anesthesia release and consent form to allow us to prepare for your pet’s upcoming procedure at Apple Tree Animal Clinic.

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Anesthesia Release and Consent Form

Be sure to review and fill out the anesthesia release and consent form correctly to help us give your pet appropriate treatment at Apple Tree Animal Clinic.

Pets Name *

Date AND Date

Owners Name *

First

Last

Email *

Phone *

Date

Procedure/Operation *

I CONSENT TO THE ADMINISTRATION OF ANESTHETICS & TO ALL PROCEDURES AS DESCRIBED TO ME BY THE VETERINARIANS AND STAFF. I ALSO UNDERSTAND THERE IS AN INHERENT RISK WITH ALL ANESTHESIA. AN ADDITIONAL FEE MAY APPLY TO DOGS OVER 80 POUNDS.
I UNDERSTAND THAT THERE IS ALWAYS A RISK OF CONTRACTING INFECTIOUS DISEASES/VIRUSES AT AN ANIMAL HOSPITAL, AND I DO NOT HOLD APPLE TREE ANIMAL CLINIC, PLLC LIABLE OR FINANCIALLY RESPONSIBLE IN ANY WAY IF MY PET CONTRACTS ANYTHING WHILE IN OUR CARE. I UNDERSTAND THAT IF FLEAS ARE SEEN MY PET WILL BE TREATED WITH CAPSTAR IN CLINIC.
TO THE BEST OF MY KNOWLEDGE, MY PET IS HEALTHY AND HAD NO SIGNS OF ILLNESS, SUCH AS VOMITING, DIARRHEA, COUGHING OR SNEEZING; AND THAT MY PET HAS HAD NO FOOD SINCE 10PM LAST NIGHT
I DO UNDERSTAND THAT THERE IS NO TREATMENT STAFF ON PREMISES AFTER CLOSING HOURS. ANY PET NOT PICKED UP BY THE CLOSE OF OUR BUSINESS DAY (MON-FRI) WILL BE KEPT OVERNIGHT AND CHARGED A BOARDING FEE
I HEREBY AUTHORIZE TERMINATION OF PREGNANCY AT THE TIME OF SPAYING MY PET. I UNDERSTAND THAT THERE IS AN ADDITIONAL FEE IF MY PET IS PREGNANT, LACTATING, IN HEAT OR OBESE. PRICES RANGE FROM $40-200 DEPENDING ON GESTATIONAL AGE.

EMERGENCY CARE *

YES, IN THE EVENT OF AN EMERGENCY, I CONSENT TO THE ADMINISTRATION OF LIFE SAVING MEASURES. PRICES RANGE FROM $500.00-$1200
NO, IN THE EVENT OF AN EMERGENCY I WISH TO DECLINE LIFE SAVING MEASURES FOR MY PET.

FOR DENTALS ONLY: *

I DO CONSENT TO AND UNDERSTAND THAT ALL EXTRACTIONS ARE AT AN ADDITIONAL COST. APPLE TREE ANIMAL CLINIC, PLLC. PROVIDES A THOROUGH CLEANING AND REMOVING OF LOOSE OR OBVIOUSLY INFECTED TEETH. IF THERE ARE COMPLICATED EXTRACTIONS YOU MAY BE REFERRED TO A SPECIALIST.

THESE PROCEDURES ARE RECOMMENDED BUT ARE OPTIONAL AND ADDITIONAL IN COST.

BLOODWORK:

Before putting your pet under anesthesia we recommend that a blood analysis be performed to ensure that your pet's vital organs are functioning in a normal and healthy manner or that they do not have an infection. COMPREHENSIVE BLOOD WORK IS REQUIRED FOR ALL DOGS AND CATS OVER THE AGE OF 6 YEARS AND IS NOT OPTIONAL.

Bloodwork *

COMPREHENSIVE BLOOD PANEL-$125 (12 panel blood chemistry -assesses kidney, liver, and electrolytes)
CBC & CHEM-$175 (Complete Blood Count- checks for possible infections in their systems and assesses blood clotting ability; 12 panel blood chemistry-assesses kidney, liver, and electrolytes)
PREP PROFILE-$45 (Checks basic liver and kidney values)
Felv+FIV TESTING-$40 Communicable Disease in CATS
Heartworm/Lyme/Ery-$50 DOGS ONLY
I decline all bloodwork for my pet.

PAIN MEDICATION:

This medication provides after-surgery pain relief for your pet to take home. We STRONGLY recommend post-operative pain medications. We administer a pain medication injection that is REQUIRED but only lasts 24 hours.

Pain Medication

Yes, I would like pain medication to be given to my pet to go home (prices range from $25-45)
No, I wish to decline pain medication for my pet to go home

POST OP SEDATION:

This medication will help keep your pet calm to make surgery recovery easier on both of you.

Post OP Sedation *

Yes, I would like post op sedation for my pet. (prices range from $25-45)
No, I wish to decline post op sedation for my pet

MICROCHIP:

This can be implanted at any time, however the needle is fairly large and it is recommended to have it done while your pet is under anesthesia. The fee is $50.00.

Microchip *

Yes, I would like a microchip
No, I would not like a microchip

Consent *

I have read and fully understand the terms and conditions described above. I certify that I am eighteen (18) years of age or older. I, the undersigned owner or authorized agent of the admitted patient, authorize Apple Tree Animal Clinic, PLLC. (its veterinarians and staff) to administer such treatments and anesthetics, both standing and emerging as necessary to perform the above mentioned procedure. I understand that no guarantee of successful treatment is either made or implied. I understand there are many risks with putting my pet under anesthesia. I understand that it is hospital policy that all charges are due and payable upon my pet's release unless other arrangements have been made. I understand that I am responsible for the cost of any additional care, including any surgical complications, needed for my pet post surgery. I understand that monitoring equipment may be accidentally left on my pet at discharge and I am expected to return it to Apple Tree Animal Clinic within one week from today or I will be billed for a replacement.

Consent *

I, THE UNDERSIGNED OWNER OR AGENT CERTIFY THAT I AM 18 YEARS OR OLDER AND AGREE TO ALL TERMS AND CONDITIONS STATED ABOVE.

Signature *

Clear Signature

Date *

Anesthesia Release and Consent Form

Anesthesia Release and Consent Form

THESE PROCEDURES ARE RECOMMENDED BUT ARE OPTIONAL AND ADDITIONAL IN COST.

BLOODWORK:

PAIN MEDICATION:

POST OP SEDATION:

MICROCHIP:

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