E-mail: 

Owner's Address: 

Last Vaccinations: 

Heartworm Prevention/Other Medications Taken:

As the owner or agent of the owner of the above animal, I hereby give my consent for the following procedures to be performed:

Signature of Owner/Agent: 

I understand that during the performance of the foregoing procedure(s), unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above. I expect reasonable care and judgment will be used in performing the procedure(s). I understand there are always potential risks when using anesthesia or performing surgery on an animal and realize that results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all reasonable costs incurred regarding this animal.

Signature of Owner/Agent: 

Date: 

If your pet is to be anesthetized, rest assured that advances in anesthesia and surgery have made routine procedures relatively safe, with a low rate of complications. Nevertheless, occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. To help detect pre-existing conditions, we recommend that all cases be screened prior to anesthesia by means of the following laboratory tests. (Canine spay, Canine neuter, Feline spay and Feline de-claw includes Pre-Anesthetic Blood Screening)

Wateree Animal Hospital strongly recommends the following for your pet:

Please initial your acceptance:

Pre-Anesthetic Blood Screen for Healthy Pets Under 7 Years of Age: BUN (kidney), clotting time, WBC (white blood cell count), PCV (red blood cell count), SGPT (liver)

Blood Screening for Pets over 7 years of age or with Health Concerns: BUN, ALT, CBC, plus tests for Glucose (blood sugar), ALP (liver), Total Protein (hydration) and Creatinine (kidney) = GHS1B (general health screen 1B)

Leukemia/Feline Immunodeficiency Virus Test: for cats not tested previously or vaccinated against feline leukemia

Heartworm Test: for dogs not currently on heartworm prevention

Other:

 Please complete the blood work which I have initialed. If abnormalities are found, please contact me at the phone number listed above.

Signature of Owner/Agent: 

  I choose to decline the recommended blood work at this time and request that you proceed with anesthesia.

Signature of Owner/Agent: 

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