____________________________ _____________________

Patient Date

 

Your pet is scheduled for a procedure that requires anesthesia. We would like to take this opportunity to explain why pre-anesthetic blood testing is important for the health of your pet.

 

Like you, our greatest concern is the well-being of your pet. Before putting your pet under anesthesia, a veterinarian will perform a full physical examination unless this was done recently. This is to identify any existing medical conditions that could complicate the procedure and compromise the health of your pet.

 

Because there is always the possibility that a physical exam alone will not identify all of your pet’s health problems, we strongly recommend that a pre-anesthetic blood profile (a combination of blood tests) be performed prior to anesthesia. The tests we recommend are similar to and equally as important as those your own physician would run if you were to undergo anesthesia.

 

It is important to understand that a pre-anesthetic blood profile does not guarantee the absence of complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future.

 

 

PLEASE INDICATE YOUR CHOICE BELOW:

 

ð_ CHEM 6 BASIC (recommended if under 6 years old) Cost: $54.00

 

BUN (Kidneys) Creatinine (Kidneys) ALKP (Liver)

ALT (Liver) Glucose (Diabetes/Sugar) Total Protein (Hydration)

Complete Blood Count (anemia, infection, clotting)

 

 

ð CHEM 12 COMPREHENSIVE (recommended if over 6 years old) Cost: $72.00

Includes all tests above, and:

 

Albumin (Protein) Phosphorus (Kidneys) Calcium (Tumors)

Total Bilirubin (Liver) Amylase (Pancreas) Cholesterol

ð I decline the recommended pre-anesthetic blood tests at this time and request that you proceed with anesthesia. I understand that a medical condition may exist which would be impossible to identify during a physical exam alone. I understand that my pet’s health could be at risk if such a condition goes undetected when my pet is placed under anesthesia.

 

_________________________________________ _________________________________________

Signature of owner (or authorized person) Phone number(s)

 

Additional Services Available Microchip ID Dental Care Nail Trim

(please circle if interested) Flea Prevention Flea Treatment

Vaccination Pet Health Insurance