_______________________    _______________   ________   ______________
Owner's Name                           Pet's Name               Age             Date

Pre-Anesthetic Blood Testing Consent Form

Like you, our greatest concern is the well being of your pet.  Your pet is scheduled for anesthesia and/or surgery.  Before putting your pet under anesthesia, we will perform a full physical examination. We also recommend that a pre-anesthetic blood profile be performed to maximize patient safety and alert the doctor to the presence of dehydration, anemia, infection, diabetes, and/or kidney or liver disease, which could complicate the procedures.  These conditions may not be detected without a pre-anesthetic profile.  These tests are similar to those your own physician would run if you were to undergo anesthesia.  In addition, the results of these tests may be  useful if your pet's health changes to develop faster, more accurate diagnoses and treatments.
State of the art equipment enables us to perform the pre-anesthetic blood profile at our clinic and we are committed to making this technology available to your pet.  Please initial on the line to your left if you wish for your pet to receive the pre-anesthetic bloodwork.

____ Healthy patients under 8 years of age ($86.66):
Testing includes: BUN (kidney), ALKP (liver), Glucose (sugar), Total Protein (hydration), ALT (liver), Creatinine (kidney), Complete Blood Count (anemia, infection, clotting)

____ Geriatric patients/ Sick patients ($113.33):
Testing includes: all the tests listed above in addition to Albumin (protein), Phosphorus (kidney), Calcium (tumors), Total Bilirubin (liver), Amylase (pancreas), Cholesterol

Other procedures your pet may have performed while under anesthesia today:
____ Dental ($54.19 for canine, $52.62 for feline)
____ Vetscope ear exam ($19.28)
____ Vetscope ear flush ($40.48)
____ Fecal examination ($16.06)
____ Bloodborn parasite test ($32.10)


______________________________________    _________________________
Owner's Signature                                                    Phone Number