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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 $66.71. 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 $47.81. 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 $34.95.
I DO I DO NOT
authorize the use of an injection of appropriate pain medication (Torbugesic-SA)
at the additional cost of $35.76.
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 $47.81. 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 $34.09. 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 $68.25. 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_______________ |