Please fill out this form before your visit.

Anesthesia Authorization Form

Call Now

BOOK APPOINTMENT

Name *

First

Last

Primary Phone *

Secondary Phone

Email *

Emergency Contact Name *

First

Last

Emergency Contact Phone *

Pet's Name *

Your pet’s safety and comfort are our number one concern. Before your pet has surgery, it will be examined for any problems that could interfere with anesthesia. During that exam, the Veterinarian may deem it necessary for your pet to have pre-anesthesia bloodwork done. By performing this bloodwork, we will be able to rule out any pre-existing internal problems that may not be physically evident but could lead to serious complications. Pre-anesthesia bloodwork will not be optional for any pet over the age of five.

I accept the recommended bloodwork
I decline the recommended bloodwork (not applicable for pets who are over 5 years of age)

Intravenous fluids provide support to the heart, lungs, and kidneys during anesthesia. An intravenous catheter will be inserted into your pet’s vein to provide access for the fluids to be given and to administer lifesaving drugs in case of an emergency.

I understand that during the performance of the dental scaling and polishing, it may be determined that some/all teeth may need to be extracted due to poor condition. There are some animals that will need specialized treatment for the root of the tooth; this will encourage the gums to re-adhere to the tooth, potentially saving some teeth from future extractions. It is not possible to determine if the treatment is needed until the procedure begins. Please initial one of the following options:

I authorize the veterinarian to proceed with extractions and/or root treatment without calling first.
I would like the veterinarian to attempt to call me before extractions and/or root treatment. If I cannot be reached, I would like them to proceed with the extractions and/or root treatment.
I would like the veterinarian to attempt to call me before extractions and/or root treatment. If I cannot be reached, I do not want them to proceed with the extractions and/or root treatment.
I decline all extractions and/or root treatment.

If there are any medications to go home, I would prefer: *

Liquid
Pills

I understand that by signing this form, I assume financial responsibility for all services rendered and agree to pay all charges incurred, including charges for medications and supplies.

Estimates are available upon request!

Signature *

Date *

Comment

Have a question?

Use the form below to send a message to our team, and we'll be in touch with you shortly. If you're in need of immediate assistance, please contact us directly at 813-633-2443.

Ready to come see us?

Book your next appointment online from any device! Simply download our app or click the "book now" button below to get started.

BOOK APPOINTMENT

DOWNLOAD APP