Millhopper Veterinary Medical Center

Dr. Richard A. Goldman & Associates

4209 NW 37th Place, Gainesville, FL  32606

352-373-8055

 

Surgical Authorization & Anesthesia Release Form

 

To make your pet's anesthetic procedure as safe as possible, our doctors and surgical staff would like you to read and understand the following information regarding required pre-anesthetic lab work, evaluations, and their associated costs.

 

A.  Preoperative Blood work.  This will enable us to choose the safest method of anesthesia and surgical procedure setup regarding your pet's individual needs.

Cost
¨ Healthy Pet Under 5 Years of Age--Packed Cell Volume (Hemocrit), Total Protein, Kidney Function (BUN) $ 25.00
¨ Healthy Pet 5 to 8 Years of Age--Complete Blood Count (CBC), Kidney Function (BUN), Blood Sugar (Glucose) $ 44.90
¨ Pets Over 8 Years of Age--Complete Blood Count (CBC), Complete Organ Chemistry Profile, Electrolytes $ 85.00
¨ I decline preoperative blood work. This option requires doctor's approval prior to admission.  
   
B.  Preoperative Electrocardiogram: An EKG can help to detect heart disease that is not apparent on physical exam.  Silent heart disease has the potential to cause problems while your pet is anesthetized.
¨ Please perform a preoperative EKG prior to anesthesia. $ 58.30
¨ No, I decline a preoperative EKG.
   
C.  IV Catheter/Fluid Therapy: This therapy will keep your pet hydrated during the procedure, and will compensate for any blood loss.  Also, the catheter provides a direct line to administer emergency medications.
¨ Please insert an IV catheter prior to anesthesia.

$ 48.50
¨ No, I specifically decline an IV catheter.  This option requires doctor's approval prior to admission.
   
D.  Pain Relief Injection.  A pain relief injection will assist in ensuring your pet's comfortable recovery.                                                                        Feline $21.10               Canine $26.10
¨ No.  I specifically decline a long-lasting pain control injection.  Please note: If the attending doctor believes that your pet's health and recovery will greatly benefit from analgesic treatment, it will be administered at the above cost.
   
E. Laser Option: Use of a laser reduces the trauma to your pet, reduces risk of infection, and improves recovery.
¨ Yes. Please use a laser rather than a scalpel for my pet's surgery.		 $ 40.50 to 64.00
   
D. Permanent Microchip. A permanent identification system by placement of a microchip underneath the skin.
¨ Yes. Please insert a permanent microchip into my pet while he/she is under anesthesia.

$ 42.30
   

PLEASE SIGN AND DATE BELOW AND ATTACH TO FIRST PAGE

Client's Name___________________________________________  Date_______________

Pet's Name_______________________________________

I am the owner of the above named patient or am responsible for this patient and I have the authority to execute this consent.  I authorize performance of the following procedures and accept full financial responsibility.

Primary Procedure_______________________________ Secondary Procedure_________________________

I hereby authorize the use of anesthetics as the doctor deems advisable and performance of the surgical or therapeutic procedures listed above.  I agree to hold Millhopper Veterinary Medical Center harmless from any liability arising from the proper performance of any procedures referred to above.

Client Signature_________________________________________   Date_______________

Home Phone ________________________ Work Phone_______________________ Other______________

________If your pet is undergoing a dental cleaning today, and during anesthesia the doctor determines that one or more teeth need to be extracted, I understand and authorize this and accept financial responsibility. (please initial)

________If your pet is undergoing a spay today and she is pregnant or in heat, there may be an additional charge at the doctor's discretion.  I understand and authorize this and accept financial responsibility. (please initial)