Montevallo Animal Clinic
3872 Highway 25, Montevallo, AL 35115
Phone: (205) 665-4625 Fax: (205) 665-2405
There is always a risk when performing anesthesia on any animal. However, complications during and following anesthesia and surgical procedures can possibly be avoided if the Doctor is aware of any underlying illness. Ailments such as anemia, liver disorders, kidney malfunction, blood clotting disorders and infections may not be evident upon physical examination. Because these and other ailments may affect surgical results and outcome, we strongly recommend that all animals undergoing anesthetic and surgical procedures have a pre-anesthetic profile.
The Profile consists of the following lab tests:
*Complete blood count *BUN – Kidney Test
*Blood glucose *CREAT – Kidney Test
*ALP-Liver Test *Total Serum Protein Test
*ALT-Liver Function *Albumin
The Cost for the profile is $63.00. The cost of the profile is NOT INCLUDED in the fee quoted for your pet’s surgery.
( ) YES, complete the blood work for my pet. If abnormalities are found, please call ______
to let me know.
( ) NO, do not complete the blood work for my pet. You may reach me at ______if needed.
I accept full responsibility for my decision.
PROCEDURE TO BE PERFORMED ______
I authorize the veterinarian to extract teeth as needed during the dental procedure. ( ) YES ( ) NO
I authorize and direct the veterinarians associated with Montevallo Animal Clinic to administer appropriate anesthesia, perform the above stated procedures and/or to do any other therapeutic procedure that their judgment may dictate to be advisable for the patient’s well-being. I understand the risks and nature of the operation and/or procedures to be performed and no guarantee has been made concerning the result or cure. I hereby authorize and direct the veterinarians to provide such additional services for the patients that may deem reasonable and necessary including the performance of or the arrangement of the performance of histopathology services and the provision of radiology services. Because ALL ANESTHEIA AND SURGERY INVOLE RISK, I further agree that the doctors and staff of performance of any of the before mentioned procedures.
*ALL PETS MUST BE UP TO DATE ON ALL VACCINATIONS*
My animal is current on ALL vaccinations ( ) Yes ( ) No
If your animal is NOT current, vaccinations will be given during the necessary procedure and added to your bill.
______Owner’s Signature Pet’s Name Date
Montevallo Animal Clinic
3872 Highway 25, Montevallo, AL 35115
Phone: (205) 665-4625 Fax: (205) 665-2405
Supplemental Pain Management Program
The past decade has seen great advancements in pain management in Veterinary Medicine. We at Montevallo Animal Clinic would like to offer out surgery patients this benefit and provide post-operative pain relief. For any of our surgery patients we do recommend pain management. For cats, this includes an injection. For dogs, this includes and injection and four days of oral medication. For more involved procedures stronger drugs may be used. One of these drugs, the Fentanyl Patch gives three to four days of pain relief. With your permission it can be applied prior to your pet’s routine surgery to provide enhanced pain control during the post-operative period.
ALL PAIN MEDICATION IS AT AN ADDITIONAL COST:
Cats:
( ) Pain Injection $22.20
Dogs:
( ) Pain Injection & Oral Medication 0-25 $24.20
( ) Pain Injection & Oral medication 26-50 $28.50
( ) Pain Injection & Oral medication 51-75 $32.00
( ) Pain Injection & Oral medication 76-100 $35.50
( ) Pain Injection & Oral medication >100 $39.50
NO: ( ) DO NOT USE PAIN MANAGEMENT ON MY PET
HOME AGAIN MICRO-CHIP
While your animal is under anesthesia a Home Again Micro-Chip may be painlessly placed under the skin. The micro-chip will be registered and placed on a data base that is used to find lost pets. $44.50
( ) Yes, micro-chip my animal ( ) No, Do not micro-chip my animal
______
Owner’s Signature Pet’s Name Date