Name *

First

Last

Email *

Preferred Contact Phone Number for Today *

Pets Name *

Procedure Location *

45th
Hillside
Plum Creek

Procedure Date *

Surgical Procedure *

Please explain. *

A physical exam alone does not allow us to know how your pet's organs are functioning. This simple test prior to anesthesia and surgery gives us a quick look at complete blood count and organ function. By knowing these values, we are better able to identify potential complications and reduce anesthetic risk. Pre-anesthetic blood work is recommended for all animals but is required for all animals over the age of 4 years. *

Previously completed (in-clinic or reference lab within 90 days)
Basic ($118.05): Ideal for pets less than 8 yrs old & less complicated procedures
Premium ($160.35): Preferred for older pets & more complicated procedures
Decline - This increases anesthetic risk.

It is well known that our pets experience pain when they have surgery. We also know that our pets recover more quickly from surgery if their pain is well managed. Some pets also benefit from oral pain medication administered at home for extended pain management. *

Accept ($35-$60): Includes a pre-operative injection and 3-5 days of oral pain medication. Cost varies on your pet's breed, weight, procedure, and current health condition.
Decline - For surgery and some dental procedures, pain management will be required.

Additional Procedures: Please check all procedures you would like performed on your pet today. These items will be added to the cost of your original estimate. *

Please explain. *

Every anesthetic procedure involves some element of risk. In the unlikely event of cardiac arrest, we need to understand what lifesaving measures we should undertake. Please select you wishes for your pet below *

Perform CPR (additional charges will apply)
Do not resuscitate (no lifesaving measures will be taken)

You have selected NOT to resuscitate your pet in the unlikely event of cardiac arrest, please confirm: *

I confirm (Please do NOT perform CPR on my pet).

By marking "Accept" below, you are certifying that you have read and fully understand this authorize for treatment. You are also stating that you are the owner or agent for the described animal and have authority to execute this consent. As the client, you assume financial responsibility for all charges incurred to the listed patient and agree to pay all charges when the animal is released from the hospital. You also understand that any procedure, especially anesthesia, involves some risk and the results cannot be guaranteed. If the animal is not current on the required vaccinations as listed, this will be done upon hospitalization and added to the cost of the listed procedures. Electrosurgery may be used during your pet's procedure. This modality allows us to minimize bleeding through cauterization of small blood vessels. If you pet has an internal pacemaker or defibrillator, please inform your veterinarian. *

I Accept
I Do Not Accept

Signature *

Pre-Anesthetic Form

Caring for the pets of Amarillo, TX

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SAC at 45th

SAC at Hillside

SAC at Plum Creek

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