Surgery Form 3 Anesthesia and Lab Consent Form - Rogue Equine & Companion Animal Clinic

Today's Date*

Owners First and Last Names*

First Last

Emergency Phone Number*

Please provide a phone number(s) where you may be reached at ALL times while your animal is in our care.

Your animal's name?*

Your animal's age?*

Sex*

Male
Male Neutered
Female
Female Spayed

Your animal's species?*

Your animal's breed?*

Your animal's approximate weight?*

Procedure to be performed:*

Please state the procedure recommended to you by the veterinarian. Noting this incorrectly may cause delays. If you are unclear, please call (541)826-9001 and ask to speak to the veterinarian recommending the procedure.

Pre-anesthetic testing - please select one choice*

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.

First Choice - 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
Second Choice - 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.
Third Choice - 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.ice
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.

To Proceed With or Without Estimate*

Please indicate whether or not you require an estimate prior to the stated procedure.

I HAVE received an estimate and elect to proceed. ** Please note - changes will be communicated as soon as possible, but may be after the procedure is completed.
I HAVE NOT received an estimate and I DO REQUIRE having received one PRIOR TO the procedure. ** Please note - this may cause delay and postponement of the procedure if not indicated in a timely manner.
I DECLINE and do not require an estimate prior to the indicated procedure.

Authorization and Risk Assessment:*

I authorize anesthesia and surgery for my animal. The nature and risks of this procedure(s) have been explained to me. I understand that some risks exist with anesthesia and/or surgery. My signature on this consent form indicates that any questions have been answered to my satisfaction.
I authorize Rogue Equine and Companion Animal Clinic to perform additional diagnostic, treatment, or procedure(s) deemed necessary for medical or surgical complications or otherwise unforeseen circumstances. While Rogue Equine and Companion Animal Clinic provides the highest quality of anesthetic monitoring and surgical services, I understand that there are rare complications associated with any anesthetic or surgical procedure. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures.
I fully understand these risks and understand that the veterinarian and hospital staff will try to minimize such risks. I will not hold Rogue Equine and Companion Animal Clinic, veterinarians, or any staff member liable for any complications that may arise.
I HAVE READ AND FULLY UNDERSTAND THIS SURGERY AND ANESTHESIA CONSENT FORM.

I AGREE AND CONSENT

Signature*

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