Feline Authorization for Anesthesia and/or Elective Surgery Feline Patient InformationPatient Name*Client Name*Client Contact Number*Perferred Contact Method (Call, Text, Email, App)*Patient AgePatient SexSpayed / Neutered?YesNoUnsurePatient BreedPatient ColorSpecial 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 has 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 fluids. Home 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 Feline Leukemia and Feline Aids test and vaccineWe highly recommend this test be performed on all feline patients at least once in their lives because Feline Leukemia and Feline Immunodeficiency Virus (Feline Aids) are viruses for which no cure exists. If your pet goes outside, we recommend administering the Feline Leukemia vaccine as well and it is recommended to run the test prior to receiving the vaccine. Please ask questions if you would like to learn more about Feline Leukemia and Feline Aids. Yes, I would like my pet to have the FeLV/FIV test (cost is $43.50).* No, I do not want my pet to have the FeLV/FIV test. Yes, I would like my pet to have the FeLV vaccine. (Cost is $22.95).* No, I do not want my pet to have the FeLV vaccine. 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*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.