Canine Authorization for Anesthesia and/or Elective Surgery Canine Patient InformationPatient Name*Client Name*Client Contact Number*Preferred Contact Method (Call, Text, Email, App)Patient AgePatient SexPatient ColorPatient BreedSpayed / Neutered?YesNoUnsureSpecial NeedsAnesthetic or sedated procedure to be performed* Spay or Neuter Surgery Sedation for Grooming Dental Service Mass or Tumor Removal Other If other procedure selected - list specific procedure belowPhysical Exams and Blood AnalysisEach patient is physically examined before anesthesia is administered. Risks do exist with anesthesia and surgery; therefore, we encourage clients to authorize pre-anesthetic blood work. (Required for pets over 5 years of age)Elective Pre-anesthetic Blood Work Authorization (includes CBC, BUN, Creatinine, ALKP & ALT (liver & kidney enzymes), Glucose, & Total Protein) STRONGLY RECOMMENDEDPre-anesthetic blood work helps to identify existing liver & kidney problems, clotting disorders and infection. I understand that if there are issues with the results, I will be contacted to discuss other options.*Yes, I would like my pet to have blood drawn and analyzed before anesthesia is administered (cost is $60.00).*No, I do not want my pet to have blood drawn and analyzed before anesthesia is administered. I understand that my pet may have underlying disease(s) that will remain unknown without bloodwork and that this may place my pet at increased risk of complications or death.Elective Pre-anesthetic Chest Radiographs Authorization STRONGLY RECOMMENDED (Required for pets over 8 years of age)Pre-anesthetic X-rays help to identify existing heart & lung problems that may not be detectable on physical exam, such as an enlarged heart. I understand that if there are issues with the results, I will be contacted to discuss other options.*Yes, I would like my pet to have X-rays before anesthesia is administered. (cost is $20.00).*No, I do not want my pet to have X-rays before anesthesia is administered. I understand that my pet may have underlying disease(s) that will remain unknown without radiographs and that this may place my pet at increased risk of complications or death.Catheterization & IV Fluids*Yes, I would like my pet to have catheterization (cost is $25.00) and IV fluids (cost is $30.00/hr) which will prevent dehydration and aid in a quicker recovery from anesthesia.No, I do not want my pet to have catheterization and IV fluidsHome Again Microchip Implant and Toe Nail Trim under Sedation Yes, I would like my pet to be implanted with a Home Again microchip. I understand the additional (cost is $41.00).* No, I do not want my pet to be implanted with a microchip now Yes, I would like my pet to have his/her toenails trimmed under sedation. I understand the additional (cost is $5.00).* No, I would not like my pet to have his/her toenails trimmed under sedation Histopath*Yes, I would like my pet to have the mass/tumor removal sent to the lab to determine a diagnosis. (cost is $142.00 for one specimen, multiple specimens increase the price).*No, I would not like my pet to have the mass/tumor removal sent to the lab to determine a diagnosis.Consent to Treat and Financial Responsibility*I am the owner or agent of the above described animal and have the authority to execute this consent. I hereby consent and authorize the performance of the above listed procedure(s). I authorize the use of appropriate anesthetics and/or other medications deemed necessary to complete the listed procedure(s). I also understand the nature of the procedure(s) and understand that risks may be involved if sedation or anesthesia is employed. I also recognize that results cannot be guaranteed. I accept full financial responsibility for the services rendered on behalf of this patient. I understand that payment is due in full upon release of this patient. Payment may be made by cash, check, Credit card, or Care Credit. I understand that Waterloo Animal Hospital, PLLC does not have a payment plan or extended credit plan. I understand the financial agreement I understand the consent to treat Signature*Date*CAPTCHACommentsThis field is for validation purposes and should be left unchanged.