PRE-ANESTHETIC BLOOD PANEL CONSENT FORM
PLEASE READ CAREFULLY, PRINT, AND SIGN. THEN EMAIL TO LOAC@ or FAX TO 270-554-0390
PRE-ANESTHETIC BLOOD PANEL CONSENT
Like you, our greatest concern is the well-being of your pet. We recommend a pre-anesthetic blood profile to be performed in order that we may maximize patient safety and inform the doctor in the presence of dehydration, diabetes and/or kidney or liver disease which could complicate the procedure. These conditions may not be detected unless a pre-anesthetic profile is performed.
Recommended for all surgical patients Cost $40.50
Includes: BUN and Creatinine (kidney) ALKP and ALT (liver)
Glucose (blood sugar) Total Protein (hydration)
Yes, please complete the blood work you recommended prior to surgery on my pet.
_________________________________ ______________________ _________
Signature of Owner Phone Number Date
No, thank you. I have elected to refuse the recommended pre-anesthetic blood work at this time and request that you proceed with anesthesia. I assume full financial responsibility for this/these animal(s). I understand there are always potential risks when using anesthesia or performing surgery on an animal.
________________________________ _____________________ _________
Signature of Owner Phone Number Date
POST SURGICAL PAIN MANAGEMENT CONSENT
We are excited to offer a new service to our surgical patients. If you choose post-surgical pain management, we will administer pain management to your pet before he/she wakes up. Our class IV therapy laser uses a beam of laser light to deeply penetrate tissue without damaging it. Laser energy induces a biological response in the cells which leads to reduced pain, reduced inflammation, and increased healing speed. This is a drug free, non-invasive approach to pain management and has been scientifically proven to be successful in treating post-surgical pain. Cost $16
Yes, please use the therapy laser to reduce pain and speed healing of my pet.
___________________________ _________________ _________
Signature of Owner Phone Number Date
No, I do not want you to administer pain management to my pet.
__________________________ _________________ _________
Signature of Owner Phone Number Date
Cell Number ___________________ Work Number ______________________
Email Address __________________________________
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