these Presurgical you

Date

Owner's Name: *

First

Last

Owner's Email: *

Patient Name: *

Species:

Sex:

Breed:

Age

Procedure to be performed: *

K9 Spay
K9 Neuter
Feline Spay
Feline Neuter

Has your pet been fed this morning?

Yes
No

General Anesthesia and Bloodwork

Your pet is scheduled for the above procedure, which involves general anesthesia. Although the veterinarians at Animal Medical Hospital at Glenwood utilize very safe anesthetic protocols and monitoring devices, there are inherent risks involved with any patient undergoing anesthesia. An IV catheter will be placed prior to the procedure, which will help facilitate quick administration of emergency medications if needed. Performing pre-surgical bloodwork within 30 days of anesthesia helps us to identify any abnormalities that would increase a patient's risk with anesthesia. It can also be a good baseline of bloodwork values for future reference.

Patients UNDER 7 Years Old

Perform CBC/Chem10 pre-surgical bloodwork with a service cost of $143.47.

Yes
Service Declined

This is optional and recommended.

Patients OVER 7 Years Old

Perform CBC/Chem17/Electrolytes presurgical bloodwork with a service cost of $192.04.

Yes
Service Declined

This is REQUIRED if bloodwork has not been performed within 30 days of surgery.

Presurgical bloodwork (CBC/Chem17/Electrolytes) Acknowledgement

I acknowledge that presurgical bloodwork (CBC/Chem17/Electrolytes) has been completed within the last 30 days.

Bloodwork performed on: *

(date performed within 30 days).

For Feline patients ONLY

Perform Feline Leukemia/FIV Test with a service cost of $109.16:

Yes
Service Declined

Note: Male cats presenting for neuter do not get an IV catheter placed.

Canine Hip and Elbow X-Rays at Time of Neuter

Many large and giant breed dogs are predisposed to having arthritis and growth abnormalities with their hips and elbows. Some breeds that are considered at ask include King Charles Cavalier Spaniels, German Shepherds, French and English Bulldogs, and Cocker Spaniels. These conditions may result in chronic pain and discomfort. Early diagnoses with the use of radiographs is the key to the identifying these conditions and decrease problems as these dogs grow.

Please x-ray my dog's hips ($280.00)
Please x-ray my dog's hips and elbows ($500.00)
Service Declined

Microchip

The cost of a microchip is $103.44 and includes your lifetime registration into the data base (done by our office).

Yes, please microchip my pet
No, please do not microchip my pet

Other Services

Are there any other procedures that have not been discussed that you would like to have performed while your pet is here?

Did you receive an estimate for today’s services?

Yes
No

Consent For Service *

I hereby authorize the use of such anesthetics you deem advisable for the performance of the above indicated procedures. I understand that the veterinarian does not occupy the building 24 hours a day, but does observe and care for the animals around the clock as needed. I agree to hold you harmless from and against any and all liability arising out of the performance of any procedures referred to above. I also understand that financial payments for said services are due when rendered and that a deposit maybe required at the discretion of hospital administration.

Signature *

Clear Signature

Emergency Phone:

Media Authorization *

I grant Animal Medical Hospital at Glenwood permission to capture my pet(s) image and likeness in photographs, video recordings, or any other media format. I grant them permission to copyright, display, publish, distribute, use, modify, print and reprint such images in business materials such as advertisements, brochures, web site images, or other social media.

Date *

Alter Spay and Neuter Consent Form