Pre-Anesthetic Authorization Blood Work SURGERY 7 AND UNDER

form for surgery patients 7 yrs and younger:

Please read carefully and sign

Your pet is scheduled for anesthesia/surgery. We require

a chemistry profile to ensure that your pet is in a low-risk

category prior to anesthesia. The latest technology has enabled

us to run safe and accurate blood chemistries minutes before anesthetic

induction. These tests are similar to those your own physician

would run when you undergo anesthesia. In addition, the results

of these tests will serve as reference values for future use

should your pet become ill.

MINICHEM / CBC - REQUIRED COST - $82.00

Complete Blood Count (assesses anemia, Blood Glucose (sugar)Creatinine (kidney)

Infection, adequate platelets for clotting)BUN (kidney)Na (sodium)

ALT (liver)ALKP (liver)

Total ProteinCL (chloride)

K (potassium)

SUPER CHEM / CBC – OPTIONAL UP GRADE COST - $103.00 (This is in addition to the surgery price)

Complete Blood Count (assesses anemia, Blood Glucose (sugar)Cholesterol

Infection, adequate platelets for clotting)BUN (kidney)Phosphorus (kidney)

ALT (liver)Calcium

Creatinine (kidney)Albumin

Na (sodium)Bilirubin (liver)

ALKP (liver)Amylase (pancreas)

CL (Chloride)K (potassium)

Total Protein

Check One: Mini Chem / CBC (Required) Super Chem / CBC – optional up grade

We believe controlling our patients’ pain is important. For that reason, we will administer medication before, during, and/or after your pet’s medical procedure to control pain, reduce discomfort and promote recovery.

Home Again Microchip

Pet identification system involves injecting a small microchip – about the size of a grain of rice – under the skin between the shoulder blades of a dog or cat. Each chip has a unique code that when registered will allow pet shelters and clinics to use the scanner to identify your pet. The price of the microchip is $54.99(This includes the registration fee.)

 YES NO

These profiles arein addition to the cost of your surgery or medical procedure. If you have any questions regarding your estimate, please call our clinic in advance.

I assume full financial responsibility for this/these animal(s). I understand there is always a potential risk for anesthesia and surgery. **Read entire sheet before signing.

______

Signature of Owner or Authorized AgentDate

Would you like to receive a text from us letting you know how your pet is after surgery? If so please leave us your cell phone number ______.PLEASE LEAVE A NUMBER YOU CAN BE REACHED AT TODAY,

DURING THE DAY: PHONE #______

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