Anesthesia & Surgery Form Anesthesia & Surgery Form I give the doctors at Avian & Exotic Animal Hospital of Louisiana (AEAH) complete authority to perform the following surgical/anesthetic procedure on my pet as described below. * I give authority Did your pet eat this morning? * Yes No Current Diet * Is your pet currently on any medication(s)? * Yes No Please list the medication(s) and when last dose given * **If fleas or mites are noted on pet upon intake, I understand I will be charged $21.00 - $68.00 (depending on weight of pet) for treatment * I understand ESTIMATE I have received and approved an estimate in the amount of $__________ for expected charges and understand the estimate must be paid in full prior to the initiation of the surgical procedure as per hospital policy. * PRE-SURGICAL WORK-UP To maximize anesthetic safety and minimize any risk of surgical complication to your pet, we recommend pre-surgical blood work to ensure that your pet's organs are functioning properly and to reveal any hidden health conditions that could put your pet at risk. Performing a chemistry panel, complete blood count (CBC), and/or full body radiographs allows us to evaluate your pet's overall health. Testing can: (1) significantly reduce medical risk, (2) allow us to proceed with confidence by knowing that results are within normal ranges or by knowing the necessary precautions and adjustments to make, (3) provide baseline level for future reference, and (4) help give you peace of mind regarding your pet's procedure. List of Services Sheet * I have been given the "List of Services" Sheet. I have NOT been given the "List of Services" Sheet. POST-SURGICAL PAIN MEDICATION If deemed necessary, I authorize the use of post-surgical pain medication at $16.53 - $18.90 * I authorize If deemed necessary, I authorize the potential use of oral supplements to stimulate the GI tract at $10.50 - $18.90 * I authorize SURGICAL/ANESTHETIC WAIVER I have been advised as to the nature of the procedure mentioned above and the risks involved in performing these procedures, and I realize that results cannot be guaranteed. I do hereby and forever release the doctors of AEAH from any and all liability arising from anesthesia and surgery on the aforementioned animal. Client's Name * Client's Name First First Last Last Pet's Name * Date * Phone * Email * Captcha Submit If you are human, leave this field blank.
