Surgery Form 2 Testing Consent - Rogue Equine & Companion Animal Clinic

Surgery Form 2 Testing Consent Form

This form is an addendum to the Surgery Form 1 Consent Form. The Surgery 1 Consent form must be completed first. Your animal is scheduled for a procedure that requires anesthesia. Pre-anesthetic testing is recommended for their health and safety. Before placing your animal under anesthesia, the veterinarian will perform a complete physical examination to identify any existing medical conditions that may complicate the procedure and compromise their health. A physical exam alone will not identity all potential health problems, thus we strongly recommend pre-anesthetic bloodwork. While pre-anesthetic testing does not guarantee the absence of anesthetics complications, the risk of complications is greatly reduced and medical conditions may be discovered which may necessitate medical treatment.

Pre-Anesthetic Testing
Your animal is scheduled for a procedure that requires anesthesia. Pre-anesthetic testing is recommended for their health and safety. Before placing your animal under anesthesia, the veterinarian will perform a complete physical examination to identify any existing medical conditions that may complicate the procedure and compromise their health. A physical exam alone will not identity all potential health problems, thus we strongly recommend pre-anesthetic bloodwork. While pre-anesthetic testing does not guarantee the absence of anesthetics complications, the risk of complications is greatly reduced and medical conditions may be discovered which may necessitate medical treatment.
Owners First and Last Names*
First Last
Pet's Name*
Select One:*
- Profile #1 -Recommended for healthy patients under 7 years of age. Includes BUN (kidney), ALP (liver), Total Protein (hydration), Creatinine (kidney), ALT (liver) and Blood Glucose
- Profile #2 -Recommended for healthy patients over 7 years of age. Includes BUN (kidney), ALP (liver), Total Protein (hydration), Creatinine (kidney), ALT (liver), Blood Glucose, Amylase (pancreas), Phosphorus (kidney), Bilirubin (liver), Albumin ([protein), Globulin (protein), Calcium, Sodium and Potassium.
- Profile #3 -Recommended for healthy patients over 7 years of age. Includes BUN (kidney), ALP (liver), Total Protein (hydration), Creatinine (kidney), ALT (liver), Blood Glucose, Amylase (pancreas), Phosphorus (kidney), Bilirubin (liver), Albumin ([protein), Globulin (protein), Calcium, Sodium and Potassium plus Complete Blood Cell Count.
- I DECLINE the recommended testing at this time and request the procedure be carried out without pre-anesthetic testing. I understand the risks involved with putting my pet under anesthesia without pre-anesthetic testing and agree not to hold Rogue Equine and Companion Animal responsible if complications occur.
Accuracy and Agreement/Consent*
I AGREE AND CONSENT
Information provided is accurate to the best of my knowledge and I understand there are additional charges for services selected above. Where a service has been declined, I understand those services will not be performed.
Date of agreement and consent*
Date Format: MM slash DD slash YYYY
Signature*
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Phone
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