Dual Pre Surgical Form

Thank you for choosing Rocky Gorge Animal Hospital for your pet’s veterinary care. Please complete the following form ahead of your pet’s procedure. Your cooperation is appreciated!

*Please provide a phone number(s) where you may be reached at ALL times while your pet is in our care.

Anesthetic Procedure Consent Form

Please provide a phone numbers where you may be reached at ALL times while your pet is in our care.

Authorization and Risk Assessment:
I authorize anesthesia and surgery for my pet. The nature and risks of this procedure(s) have been explained
to me. I understand that some risks exist with anesthesia and/or surgery. My signature on this consent form
indicates that any questions have been answered to my satisfaction.

I authorize Rocky Gorge Animal Hospital to perform additional diagnostic, treatment, or procedure(s) deemed
necessary for medical or surgical complications or otherwise unforeseen circumstances. While Rocky Gorge
Animal Hospital provides the highest quality of anesthetic monitoring and surgical services, I understand that
there are rare complications associated with any anesthetic or surgical procedure. No warranty or guarantee
has been given to me as to the results or cure afforded by these treatments or procedures.

I fully understand these risks and understand that the veterinarian and hospital staff will try to minimize such
risks. I will not hold Rocky Gorge Animal Hospital, the veterinarians, or any staff member liable for any complications that may arise.

While your pet is in our care, we always want to be prepared with your wishes. In the event your pet should go into cardiac or respiratory arrest, we need to know how you would like us to proceed.

Pre-Anesthetic Testing Consent

Your pet is scheduled for a procedure that requires anesthesia. We would like to take this opportunity to recommend pre-anesthetic testing and explain why it is important to the health of your pet. Like you, our greatest concern is the well being of your pet. Before placing your pet under anesthesia, one of our veterinarians will perform a complete physical examination to identify any existing medical conditions that would 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 pre-anesthetic bloodwork to be performed prior to anesthesia. It is important to understand that a pre-anesthetic does not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future.

PROFILE #1 CHEM 10 

Recommended for healthy patients under 7 years of age. - Bun (Kidney) - ALKP (Liver) - Total Protein (Hydration) - Albumin (Protein) - Creatinine (Kidney) - ALT (Liver) - Blood Glucose

PROFILE #2 CHEM 17/CBC

Required for healthy patients over 7 years of age. - BUN (Kidney) - ALKP (Liver) - Total Protein (Hydration) - Lipase (Pancreas) - Creatinine (Kidney) - ALT (Liver) - Blood Glucose - Amylase (Pancreas) - Phosphorus (Kidney) - Bilirubin (Liver) - Cholesterol - Albumin (Protein) - GGT (Liver) - Calcium - RBC count (Anemia) - WBC count (Infection)

Month & Year
Checking this box certifies that I agree to be bound by the terms and conditions stated in this form.

Surgery & Anesthesia Questionnaire

*PLEASE NOTE: The doctor will only extract teeth in the best interest of your pet. Please be aware that tooth extractions and dental radiographs are NOT included in the price of the dental cleaning, and the owner will be responsible for the extra cost. THE OWNER WILL NOT BE CALLED FOR PERMISSION TO PULL TEETH WHILE THE PATIENT IS UNDER ANESTHESIA.
If requested; a therapeutic laser will be used (with some exceptions) on the incision(s) to help speed the healing process, reduce pain and inflammation, and reduce the formation of scar tissue. This, along with our standard pain management medications, will provide your pet with the best in pain and wound care management.