ORION - Medical, Anesthetic, and Pre-Surgical Release Form

Medical, Anesthetic, and Pre-Surgical Release Form
Client Name*
Client Email*
example@example.com
Patient Profile
Name*
Breed*
Weight*
D.O.B*

MonthDayYear
Date
Type
Sex*

MaleFemaleNeuteredSpayed
Procedure(s)
Surgical Options

I authorize implantation of a microchip - $65.49I authorize a histopathology (biopsy) - $200+I authorize laser therapy after the surgical procedure to promote fast healing - $45.99 (per treatment)I authorize a nail trim to be done under anesthesia - $19.99I authorize necessary dental extractions (prices vary)
I authorize the following

e-collarbody suitI have an e-collar at home
I request a sedative for recovery at home*

YesNo
Emergency resuscitation preference*

CPR: Stabilize your pet then contact you. This can consist of chest compression and injections up to $275DNR: 'do not resuscitate' where CPR is NOT to be performed
Medical Care Requirements
I, hereby authorize Orion Animal Care Center to perform these following procedures, operations, placement of an IV catheter and associated anesthesia for Ginger. I understand that unforeseen conditions may require an extension of a planned procedure or operation. I am aware that unforeseen events resulting from the procedure does not relieve me from any obligations to all reasonable costs incurred regarding this patient. I authorize any procedures that are necessary and advisable in the professional judgement of the veterinarian.

Pre-Surgical Blood Analysis: Risks can greatly be reduced with the ability to evaluate your pet's ability to utilize and metabolize medications and anesthetics. The blood analysis detects most underlying problems and evaluates major organ functions that are responsible for filtering anesthesia through the body while also checking for signs of anemia and/or signs of infection that could cause complications during the procedure. The pre-surgical blood analysis selected by the doctor will check specific kidney and liver functions as well as blood glucose and hydration status. Our priority is your pet's health and well being. We reserve the right to decline surgical procedures on any pet that is not current on vaccines and blood analysis.

Should unexpected life-saving emergency care be required in the event of arrest, your pet may require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, or other interventions.
Consent*

I understand that the administration of anesthesia involves some risk to my pet, including rare reactions to medications and possible death. I consent to the use of medications as deemed necessary by the attending veterinarian.I understand that all procedure and surgery also involve some risk to my pet. The most common risks include, but are not limited to, bleeding, nerve damage, and infection.I understand that the doctors and staff at Orion Animal Care Center will use all reasonable precautions against injury, escape, complications, and death.
Phone number(s) where you may be reached all day
I understand that Orion Animal Care Center will make every reasonable effort to contact me prior to performing additional procedures outside of my estimate. If I cannot be reached, an additional anesthetic procedure may be required in the future to avoid keeping my pet under anesthesia longer than necessary*

I agree
Statement of Financial Responsibility
I have received an updated cost estimate for my pet's procedure/treatments with a range
$ Min
$ Max
I agree to pay the full amount of my pet's invoice at the time of discharge*

Yes
Additional Comments
I HAVE READ AND UNDERSTAND THIS AUTHORIZATION AND CONSENT FORM*

Yes
Signature of Owner/Agent*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Medical, Anesthetic, and Pre-Surgical Release Form

Patient Profile

Medical Care Requirements

Statement of Financial Responsibility