ANIMAL GENERAL OF CRANBERRY 20411 Rt. 19 LaSalle Plaza, Unit 10

Cranberry Twp., PA 16066 724-776-7930

PRE-ANESTHETIC AND SURGICAL RELEASE FORMPlease Read Carefully and Sign

Client Name: _________________________________________________ Date: ___________

Pet’s Name: ____________________________Procedure: _____________________________

I, the undersigned owner, hereby authorize any emergency medical or surgical treatment deemed necessary for the health and well being of my pet _________________________ during its stay at the Dr. Michael Hutchinson D.V.M., P.C. facility. I further understand that, regardless of age, Dr. Michael Hutchinson D.V.M., P.C. requires a pre-anesthetic blood screen. Our doctors use safe anesthetic and surgical protocols to minimize risk to your pet. No anesthetic or surgical procedure, however, is completely without risk to your pet. Although modern veterinary anesthetics are generally considered safe, problems can still occur. Complications from an anesthetic may range from mild nausea to prolonged recovery due to an organ problem (kidney or liver), to very rarely, death. These tests allow us to uncover important information regarding potential underlying problems that may affect your pet’s ability to safely undergo anesthesia. We strongly advise that these tests be done.

Pre-Operative Blood Work: Please indicate level of blood work you would like us to perform.

Recommended for: Blood Values examined: Fee:

____ Level 1 Healthy pets under age of 2yr Glucose, BUN, PCV, total protein $41

____ Level 2 Healthy pets between 2-7yrs Prep Profile II (mini chem) with CBC $95

____ Level 3 All patients over 8 years of age and/or health problems

Complete CBC/CHEM/T4 $142

Level of blood work may be subject to change by discretion of Doctor depending on conditions

I would like Dr. Michael Hutchinson D.V.M., P.C. to perform a pre-anesthesia blood screen on my animal listed above. I understand that I will be charged the above fee for this service.

Signature: ___________________________________________ Phone #: ________________

I understand the risks of both anesthesia and surgery, and I DO NOT WANT DIAGNOSTIC TESTS for my pet for this procedure.

Signature: ___________________________________________ Phone #: _________________

Please indicate if you would like us to perform any of these additional servicesPlease check one box in each category

Post-operative Pain Control:Pain control can greatly improve both comfort and healing during the post-operative recovery period. Pain management ranges from in hospital injections and/or oral medication to send home with the patient.

___ Cats – pain injection – lasts 2-3 days post-surgery - $23___ Dogs – pain injection – lasts 24 hours – injection only - $25 - $30___ 4 days worth of oral anti-inflammatory/pain medication to go home - $20 - $30___ 24-hour pain injection & oral medication to go home - $45 - $53

___ I decline pain medications for my pet after surgery

Microchip Permanent Identification:This is an excellent way to permanently identify your pet should they become lost or stolen. Microchipping is performed easily while your pet is sedated for surgery.

Cost $35 to implant, additional fee for registration through company.

___ Yes, I would like my pet micro-chipped during anesthesia. I understand I will be charged the additional fee above.

___ No, I decline the microchip at this time.

Intravenous Catheterization and IV Fluid Therapy:These allow us to maintain blood pressure, replace blood loss, speed recovery, and administer life-saving drugs in case of an emergency. These options are recommended for all pets undergoing general anesthesia.

Cost $74

___ Yes, I accept IV catheterization and fluid therapy for my pet. I understand I will becharged the additional fee above.

___ I decline IV catheterization and fluid therapy for my pet.

Additional Routine Screening Tests:

Cats:___ FeLV/FIV blood test. $47.00 (recommended once in all cats)

Dogs:___ Heartworm blood test. $27.00 (done at 6m or older and every 2 years while on preventative)

___ I decline routine screening tests for my dog or cat.