Anesthesia Release and Surgical Consent Online Form Client InformationDate of Procedure* MM slash DD slash YYYY Client Name* First Last Pet's Name* First Phone*Email* Procedure(s)*Please indicate what procedure(s) will be performed today.Anesthesia ReleaseRelease* I agree to the Anesthesia ReleaseI understand that my pet’s procedure requires general anesthesia and /or sedation. All precautions will be taken to insure the safety of my pet. However, I have been informed of the possible risks associated with anesthesia /sedation, and that I am responsible for associated charges. I also understand that the doctor(s) reserve the right to perform lifesaving efforts should complications arise. I officially release Asheville Highway Animal Hospital of any liability pertaining to this procedure (before, during, or after surgery). Electronic Signature* First Last By electronically signing you hereby agree to the consent.Today's Date* MM slash DD slash YYYY Diagnostic TestingWith all anesthetic procedures, problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. To avoid these problems, we require that all patients 6 years and older be screened prior to anesthesia by means of the following laboratory test. We highly recommend this screening be done for all patients regardless of age. Please approve or decline by selecting the appropriate option below. (FYI: All Spays and Neuters receive a basic kidney & liver panel included in the cost of surgery. For spay/neuter patients over 6 years old, an additional CBC is required.)Screening Panel Plus* My pet is over 6 years of age and had blood work prior to procedure My pet is over 6 years of age and has NOT had blood work prior to procedure. I approve for it to be done My pet is under 6 years of age and had blood work prior to procedure. My pet is under 6 years of age and has NOT had blood work prior to procedure. I approve for it to be done. My pet is under 6 years of age and has NOT had blood work prior to procedure. I do NOT approve for it to be done. My pet is having a Spay or Neuter procedure. If additional bloodwork is required due to age or medical concern, please notify me of additional bloodwork needed. Screening Panel Plus- This checks for: anemia problems, clotting blood, hidden infections, kidney or liver problems, low blood sugar, dehydration.Electronic Signature* First Last By electronically signing you hereby agree or decline blood work based upon your above choice.Today's Date* MM slash DD slash YYYY Additional ServicesPlease note any additional services that you would like us to perform while your pet is anesthetized.Additional Services*NoneNail TrimMicrochippingEar CleaningTeeth BrushingFull Dental CleaningGrowth RemovalHeartworm TestFeline Leukemia TestAnal Gland ExpressionHold CTRL on keyboard to select multiple at once.PhoneThis field is for validation purposes and should be left unchanged.
