Evergreen Animal Hospital
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Surgical Authorization Form
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As the owner/agent of this pet, I hereby grant my consent and authorize the veterinarian and staff at Evergreen Animal Hospital to
treat, anesthetize, and/or operate
upon my pet. I understand that during the performance of this procedure
, unforeseen conditions may occur that require extension or variance of the planned procedure(s
). I understand that the nature of the procedure(s) and risks involved; I realize the results cannot be guaranteed. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all costs incurred regarding the animal. Evergreen Animal Hospital will perform the procedure/surgery to the best of their ability; the hospital makes no guarantee or warranty regarding the results and I will not hold them liable.
Pre-Anesthetic Blood Panel
Anytime an animal goes under anesthetic, there is a risk for problems to arise due to pre-existing conditions not evident from a physical exam alone. To help reduce the risk of such problems,
we recommend a pre-anesthetic blood panel for your pet.
While this panel will not guarantee the absence of problems while under anesthetic, it may allow for the detection of factors that may lead to such problems. The pre-anesthetic blood test evaluates kidney and liver function which are essential organs in the metabolism and recovery of anesthetic. It also checks for diabetes.
The blood test is an additional $86.60
Post-Operative Pain Management
Every patient receives a painkiller injection during surgery when the veterinarian deems it necessary. If you would like us to
send home follow-up pain medication
, please confirm that decision here.
Would you like your pet to go home with pain management?
YES, I want my pet to go home on follow up pain medication
NO, I do not want my pet to go home with follow up pain medication
A complimentary nail trim and ear flush will be performed while your pet is with us, please select any of the following services you would like performed while your pet is under anesthetic.
Anal Gland Expression
OTHER (please describe)
If your pet is overdue on any vaccinations or due soon, would you like to update them today?
We will contact you as soon as your pet’s procedure is complete. A technician will explain all pertinent information regarding the procedure at at-home care. Payment in full is required at the time of pickup.
By electronically signing below, I agree I have read and understand the terms of the above document. I give Evergreen Animal Hospital permission to perform the procedures as described above.
Any other notes/requests for Dr. Burton please enter below
Monday - Friday
7:30am - 5:30pm
Saturday & Sunday
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