Lake Zurich Animal Hospital
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Dr. Steven Pritkin D.V.M. ~ 900 Winnetka Terrace ~ Lake Zurich, IL 60047

Phone 847-438-3750 ~ Fax 847-726-8991

STANDARD CONSENT FORM FOR ELECTIVE PROCEDURES

Owners Name____________________________________________________ Pets Name____________________

Breed____________________ Coloring__________________ Sex______ Age________ Weight______________

Phone # where I can be reached today ___________________________________________ Date ______________

I am the owner of the above named animal or am responsible for them and I have the authority to execute this consent. I authorize the performance of the following procedure(s):

_____________________________________________________________________________________________

I also authorize the use of any anesthetics as you deem advisable in the performance of surgical, diagnostic, or therapeutic procedures. I realize that the administration of any anesthetic agent carries a small but realistic possibility of side effects which do include death.

I recognize the nature of the surgical procedure(s) being performed and realize that certain risks and complications may be involved. I acknowledge that no guarantee or assurance bas been made as to the results that may be obtained.

Please circle your choices below:

I DO     I DO NOT authorize the performance of a pre-anesthetic/surgical/dental blood screen at the additional cost of $58.53. I realize that I will assume responsibility for all risks and complications that may arise if this blood screen is not performed.

I DO     I DO NOT authorize the performance of a pre-anesthetic/surgical/dental screening electrocardiogram (EKG) at the additional cost of $45.53. I realize that I will assume responsibility for all risks and complications that may arise if this EKG screen is not performed.

I DO     I DO NOT authorize monitoring of blood oxygen (Pa02) and EKG (heart impulses) during surgery. A pulse oximeter & EKG will monitor your animal during surgery. This is optional but we highly recommend this level 2 monitoring. Because of the costs of a pulse oximeter, EKG, and the extra time needed to install the monitoring equipment, there will be a charge of $33.29.

I DO     I DO NOT authorize the use of an injection of appropriate pain medication (Torbugesic-SA) at the additional cost of $34.06.

I DO     I DO NOT authorize the administration of sterile subcutaneous fluids (Lactated Ringer) to assist my pet in its recovery at the additional cost of $45.53. I understand that my pet should not have had any food or water for at least twelve hours prior to anesthesia and dehydration is an obstacle to a quick recovery.

YES      NO      I would like my pet's eyes checked for interocular pressure (I.O.P.) at the additional cost of $32.47. This is to test for the painful disease of glaucoma.

YES      NO      I would like the doctor to implant the HomeAgain Microchip at the additional cost of $65.04. This is to identify my pet if it is ever found wearing no collar or tags.

YES      NO      My animal is updated on all required vaccinations. If no, please give the appropriate vaccinations. Additional charges will apply.

I agree to indemnify and hold Dr. Steven Pritkin and employees harmless from and against any liability arising out of the performance of any of the procedures referred to above.

Signature_________________________________________________________________ Date_______________