400 Bethlehem Rd.  Paris, KY 40361
(859) 987-6721

SURGERY & ANESTHESIA CONSENT

Owner:						Date:  
Address: 

Phone(s):					Phone # to be reached during your pet’s visit:     
Patient: 
Date of Birth:					Sex: 
Breed:						Color:		
Main Reason For Admittance:  

I hereby authorize and direct the veterinarians of Central Kentucky Veterinary Services to perform the procedures and additional diagnostic and/or treatment procedures as deemed advisable for my pet. The procedure(s) has/have been explained to me and no guarantee has been made as to the results or cure. I understand that there may be risks involved in some of these procedures.

I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Any estimates or charges for the planned procedures are only approximations, and the final bill may be greater or less than these amounts. All services must be paid for when released.  Some procedures require a deposit be made before surgery.

Like you, our greatest concern is the well-being of your pet.  A physical examination will be performed before anesthetizing your pet.  However, many conditions including disorders of the kidneys, liver, heart & blood cannot be detected without blood lab screening.  For this reason, we highly recommend pre-operative screening before sedating your pet.  Please mark the appropriate options below:

 I DO authorize the recommended Pre-surgical Blood Screen.  The cost is $49.50 if done prior to the day of surgery.  The cost is $62.00 if done in-house on the day of surgery.
 I DO NOT authorize the recommended Pre-surgical Blood Screen. I understand and assume all responsibility for additional risks/complications resulting from refusal to approve this blood screening for my pet’s safety.
         
I would like my pet to have a pain relief injection prior to surgery.**  	 YES           If necessary	        NO	
	
I would like my pet to have pain relief medication dispensed to use at home.**	 YES	        NO	
																
Are vaccinations and laboratory tests current today (within the last year)?	      	 YES	        NO	

Did your pet eat this morning?	 YES	     NO
	
Elective Procedure to be done while your pet is anesthetized (please check):
 Toe-nail Trim (complimentary)  	 Dremel Nail Trim**  	 Update Vaccinations**	 Remove Baby Teeth**
 Microchip Identification**  		 Express Anal Glands**   Ear Cleaning/Flushing**  	Correct Umbilical Hernia** 
 Feline Leukemia/FIV Test** 	 Heartworm/Erlichia/Lyme Test**
Other Requested Procedures**     
**Items marked with asterisk are at an additional charge & not included in the price of the surgery.
I have read and fully understand the foregoing and agree completely to all terms and conditions.

Signature:								Date: