Surgery Laser Consent Form Owner's NamePet's NameDate MM slash DD slash YYYY HistoryIs your pet allergic to any drugs? Yes No Has your pet has any illness or injury in the past 30 days? Yes No Any history of seizures and/or previous anesthetic problems. Yes No Current medications? Yes No Procedure to be Performed OVH/Spay Neuter Dental Declaw Other Elective Procedures to be done at the same time Ear Flushing $25 Repair Umbilical Hernia Laser Removal of Warts/Skin growths $50 for 1st and $25 for each additional Ear Cleaning $5 Routine Nail Trim free Remove Dewclaws with Laser Microchip Implant and Registration $67.99 Trim and Electric File Nails $15 Dental Procedures to be preformed with any other surgery Extract Baby Teeth Fluoride Application $14 Owner Release For the enhanced protection of our patients, we recommend the following screenings/procedures for all pets prior to administration of anesthetics. These are optional for additional costs.I authorize the recommended Pre-Surgical Blood Screening w/ CBC at the cost of $65. I understand that I assume all responsibility risk/complications resulting from my refusal of this service. (We highly recommend any animal over 7 years of age have Pre surgical Blood Screening. If Blood screening not elected veterinarian has the option of declining surgery based upon age and quality of your pets health. ) Yes No I authorize a Pre anesthetic Electrocardiogram (EKG) at the cost of $20. I understand that I assume all responsibility for additional risk/complications resulting from my refusal of this service. Yes No I authorize a Pre anesthetic Blood Pressure at the cost of $30 and $16 if you chose EKG. I understand that I assume all responsibility for additional risk/complication resulting from my refusal of this service. (We highly recommend any animal with Thyroid or Heart conditions have their Blood Pressure checked.) Yes No I authorize a IV Catheter at the cost of $32. Should an emergency arise (i.e. reaction to anesthesia, excessive bleeding, etc.) already having venous access allows immediate/more rapid drug administration and may increase chances of survival. Yes No You are to use all reasonable precautions against injury, escape or death of my pet. I understand that anesthesia and surgeries always involves some risks to my pet and agree to hold you harmless, in the absence of negligence, in connection with these procedures. In the event complications arise and I cannot be immediately contacted at the below listed phone number, you are directed to make the decision you deem best for my pet. I have read the foregoing, understand what it says, and agree. Signature*Date* MM slash DD slash YYYY Emergency Phone number where you can be reached today*I have received and understand all discharge instructions giving to me at the time of my pet’s surgery release. Signature*As part of our commitment to quality care, we are pleased to offer laser surgery as an option for safe, comfortable treatment for your pet. We feel that laser surgery provides the best possible care for your pet.The benefits of laser surgery are: Less Pain – the laser seals nerve endings as it “cuts”, so your pet may require fewer anesthetics during the operation, also reducing pain after the surgery. Less Bleeding – the laser seals small blood vessels during the surgery, greatly reducing blood loss. Less Swelling – the laser energy does not crush, tear, or bruise the tissue because there is no physical contact with the tissue. Your pet will be treated with a carbon dioxide laser, which produces an invisible beam of light that can remove a precise layer of tissue at one time. This can reduce your pet’s post-operative recovery time, leading to a quicker return to normal activities.I understand that laser surgery is an option and I have been advised of the advantages the procedure will offer.Yes, I want my pet to have laser surgery and understand the costs listed below are in addition to normal surgery costs. Yes Level I: $40 (spays, neuters, minor skin lesions such as warts, etc.) Level II: $70 (oral surgery, eyelid repair, etc.) Level III: $100 (declaws , larger tumor removals, etc.) Level IV: $110-$210 (mammary tumors, cosmetic procedures, soft palate, etc.) Laser wart removal with local Anesthesia for $25, then $50 for first wart and $25 for each additionalI decline laser surgery for my pet. No Patients Name*Client Number*Signature*Date* MM slash DD slash YYYY
