MT. TABOR ANIMAL HOSPITAL

AUTHORIZIATION FOR MEDICAL AND/OR SURGICAL TREATMENT

PATIENT’S NAME____________________________ PROCEDURE_____________________

I am the owner/agent for the above named pet and hereby consent and authorize the medical staff at Mt. Tabor

Animal Hospital to perform the above procedure. If in the process a situation arises in which the Doctor feels

additional and/or different diagnostic or therapeutic procedures are necessary, I am to be contacted. If the

attempt is unsuccessful, I give permission for the Doctor to treat my pet at his/her own discretion.

During the anesthetic procedures we routinely monitor your pet with pulse ox, EKG, and blood pressure

machines. If at any time your pet’s vital signs drop to an unsafe level, Mt. Tabor Animal Hospital has your

permission to administer IV medications and fluids.

I consent to the administration of anesthesia as deemed appropriate by the Doctor. I understand that any surgical

procedure carries with it potential risk. I realize that results cannot be guaranteed.

IN ORDER TO BETTER EVALUATE YOUR PET’S HEALTH AND ABILITY TO METABOLIZE THE

ANESTHESIA, THE FOLLOWING TESTS ARE RECOMMENDED:

YOUNG ANIMAL BLOOD TESTS – FOR PETS UP TO FIVE YEARS OF AGE. This includes total protein, glucose, BUN,

CBC, potassium chloride, and sodium. THE FEE IS $47.61. SIGN TO ACCEPT ____________________________________

MIDDLE AGED BLOOD TESTS – FOR PETS FIVE TO NINE YEARS OF AGE. This includes total protein, glucose, BUN,

CBC, creatinine, alkaline phosphatase, alanine aminotransferase, albumin, potassium chloride, and sodium. THE FEE IS

$84.31. SIGN TO ACCEPT ________________________________

COMPREHENSIVE BLOOD TESTS – FOR PETS NINE YEARS AND OLDER. This includes total protein, glucose, BUN,

CBC, creatinine, alkaline phosphates, alanine aminotransferase, albumin, phosphorus, total bilirubin, potassium chloride, and

sodium. THE FEE IS $124.15. SIGN TO ACCEPT _____________________________

I DECLINE all recommended blood tests. I understand that this increases the risks of anesthesia and I take full responsibility.

SIGNATURE OF OWNER/AGENT ______________________

While my pet is under anesthesia, I request the following procedures be done:

NAIL TRIM ($12.82) ____________ HOME AGAIN MICROCHIP ($48.70) ___________

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DENTALS ONLY

If my pet is undergoing a dental cleaning and /or tooth extraction, it is recommended the doctor attempt to

contact me. If unable to contact me please: (initial appropriate permission)

Extract teeth as the Doctor deems necessary ________ Please do not extract any teeth ________

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We recommend an IV catheter be inserted during surgery with your permission at an additional cost of $25.25.

ACCEPT ____________ DECLINE _______________

Signature of owner ___________________________________

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I hereby certify that I have read and fully understand the above authorization form for the above

mentioned medical/surgical procedure.

SIGNATURE OF OWNER/AGENT ________________________________________ DATE _______________

Print Name _______________________ Phone number at which I can be reached ____________________

PRESURGICAL BLOODWORK IS REQUIRED FOR PETS 10 YEARS AND OLDER

DUE TO HIGHER RISKS.