Authorization For and Consent to Anesthesia and

Surgery or Diagnostic/Therapeutic Procedure

Please read carefully and sign.

Placing animals under anesthesia and performing procedures carries certain risks. Some animals
may have sensitivities or reactions to the medications used that cannot be predicted. While we at
Monticello Animal Hospital enjoy an extremely low rate of anesthetic complications, it is important
that you are aware of the inherent risks of these procedures. We include IV fluids with our routine
anesthetic procedures. Placement of an intravenous (IV) catheter will allow delivery of IV fluids to
assist in the maintenance of blood pressure and allow rapid access for drug administration in the
event an emergency situation develops. A licensed veterinary nurse and additional monitoring
equipment such as an electrocardiogram (ECG), respiratory, blood pressure, and pulse oximetry
units monitor each patient during anesthesia.

Disorders of the liver, kidneys, and/or blood are not always detected by physical examination
alone. To minimize risks, selected laboratory tests can help to assess your pet’s ability to safely
undergo anesthesia and identify certain potential problems that could endanger your pet. Our
hospital is fully equipped to perform these blood tests and have the results available before
anesthesia.

Pet Health Screen 1 $130.00 Pet Health Screen 2 $160.00

Healthy patients less than 5 years of age. Patients older than 5 years or with questionable
Includes: health status.
 Complete blood count (assesses anemia, Includes all the tests in Pet Health Screen 1 plus:
infection, clotting)  Cholesterol
 BUN (kidney)  Phosphorus (kidney)
 TP (hydration)  Total Bilirubin (liver)
 Blood Glucose (sugar)  GGT (liver)
 ALKP (liver)  Globulin (immune status)
 ALT (liver)  ALB (protein)
 Creatinine (kidney)  Calcium (certain cancers)
 Sodium
 Potassium
 Chloride

_____ YES, please complete the blood work you recommend prior to surgery on my pet. If
abnormalities are found please call and inform me at the number below.

_____ NO, I have decided to DECLINE the pre-op blood work recommended at this time and
request that you continue with the surgical procedure.

Please initial beside the option you choose and complete page 2
Anesthesia Consent Form: Page 2
If other procedure(s) are found to be necessary in order to avoid a second anesthetic event:

______ Please CONTACT ME at the number below. DO NOT perform any other service until I
have been reached for verbal consent.

______ Please CONTACT ME at the number below, if you cannot reach me at the numbers below
proceed with the procedures that my pet’s veterinarian finds to be necessary to avoid a
second anesthetic event. (i.e. hernia repair, removal of retained baby teeth, or removal of a
broken or diseased tooth) Consent implies acceptance of charges for services. Charges will
be itemized and reviewed with you when we are able to reach you.

______ Please PERFORM other procedures that my pet’s veterinarian finds to be necessary to
avoid a second anesthetic event. Consent implies acceptance of charges for services.
Charges will be itemized and reviewed with you when we call to let you know your pet is
recovering from his/her procedure.

I understand the anesthetic and surgical, diagnostic or therapeutic procedure may involve risk of
complications, injury or even death, from both known and unknown causes and no warranty or
guarantee has been expressed or implied as to result or cure. I authorize the hospital staff in an
emergency situation, to follow through with such procedures as are necessary for the well being of
my pet on a continuing basis until further communication with me. I agree to assume financial
responsibility for all routine and emergency services rendered.

Please sign below acknowledging that you have read the above, the procedure(s) have been
explained to your satisfaction, you have had a chance to ask questions, and that you authorize and
consent to the performance of the procedures and to the administration of anesthesia.

_______________________________________/___________
Signature of Owner/Owner’s Agent Date

YOUR PREFERRED CONTACT TODAY REGARDING YOUR PET:

□ Phone/ □ Text Message/ □ Email : _______________________________________________

Alternate Contact: _________________________________________________________________

Optional Services: Please initial by the service(s) you would like performed.

__________ Microchip Implant w/ Registration $69.50

__________ Toe Nail Trim w/ Anesthetic Procedure $12.00

__________ Toothbrush Kit $14.00

__________ Other: _____________________________ Price: __________

_____________________________ Price: __________