Bocage Animal Hospital

7353 Jefferson Highway

Baton Rouge LA 70806

225-928-7550

Surgery Waiver

Owner: ______

Address: ______

City, State, Zip: ______

Pet’s Name: ______Species: ______Breed: ______Color: ______

Age: ______Sex: ______

______will be undergoing surgery for ______on ______(date).

I have also been informed that there are certain risks and complications, including death, associated with any operation or procedure of this type. I further understand that during the course of the operations or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures.

Please initial in the spaces provided below to authorize or decline medical procedures.

Blood Work

Basic anesthesia charges include an initial physical exam, pre-anesthetic assessment of anemia or kidney disease, and monitoring of cardiac function during anesthesia. I understand that underlying disease may increase anesthetic risk, especially in animals over 5 years of age or in ill animals. The doctor’s choice of anesthetic medications may be altered accordingly if pre-existing problems are known. Pre-anesthetic blood work will be run in order to determine if surgery will be performed to help to alert the doctor to these

conditions. As the responsible owner/party I understand these conditions. ______

Micro Chip

We offer identification microchips for <______>. This chip can be injected while your pet is under anesthesia. The benefit of having your pet chipped is permanent identification for the life of your pet. Your pet will have a one-of-a-kind number that is specific to only to them.

I ______authorize / ______decline to have <______> micro chipped while under anesthesia at a cost of $49.00.

“Living Will” Clause

In the event of life-threatening complications, I ______authorize / ______decline the use of measures to revive <______>.

Dental Extractions

If <______> is having any dental procedures today there is always a possibility they will need extractions. The doctor will examine all teeth while <______> is under anesthesia and determine which, if any, teeth will require extraction. Simple or complex extractions may be necessary at an additional cost. I ______authorize / ______decline extractions. Does not apply to <______>

Pain Control Clause

I understand that surgical procedures result in pain. The doctors and staff of Bocage Animal Hospital strongly recommend post-operative pain medications. I understand that no medication will completely relieve pain. The doctor will prescribe the medication he/she feels is best for <______>.

I ______authorize / ______decline pain medication to be prescribed for <______>.

I am the owner or the agent for the owner for the animal described above, and I have the authority to execute this consent.

Signed: ______Date: ______