Procedure Consent Form

Owner's Name*

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Date

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Email *

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Pet's Name

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Procedure(s) to be performed

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To minimize risks, we recommend selected laboratory tests which can help to assess your pet’s ability to safely undergo anesthesia or sedation and identify certain potential problems that could endanger your pet. An intravenous (IV) catheter will be placed at the doctor’s discretion to allow delivery of IV fluids to assist in the maintenance of blood pressure and allow rapid access for IV drug administration in the event an emergency situation develops.

The charge for the IV fluids is $47.00 and may or may not have been specifically detailed in any estimate.

Please Indicate Your Choices Below

I want to have an optional pre-anesthetic blood screen performed. Cost: $50.00 for animals under 8 years of age. $60.00 for animals 8 years of age or over. (a more extensive profile).

Yes No

I do not want to have a pre-anesthetic blood screen performed. (Certain procedures have mandatory blood screening)

Yes No

Microchipping is available while your pet is under anesthesia and is required for all City of El Paso animals over 4 months of age.

Cost: $28.15 (includes registration to a national database)

Yes No

Heartworm testing and tick-borne disease screening is recommended annually for dogs that are not on the preventative or who are not on year-round preventative, and every 2 years for dogs on year-round preventative.

Cost: $42.94 ($35.50 with a pre-anesthetic screen)

Yes No

Feline Leukemia (FELV) and Feline Immunodeficiency Virus (FIV) testing is recommended for cats that have never been tested, kittens with unknown maternal vaccinations, or cats with outdoor exposure and not current on FELV vaccinations.

Cost: $43.50 ($38.75 with a pre-anesthetic screen)

Yes No

RISK DISLAMER FORM

I understand the above anesthetic and surgical or therapeutic procedures may involve risk of complications, injury or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure. I authorize Crossroads Animal Hospital staff in an emergency situation, to follow through with such procedures as are necessary for the well being of my pet on a continuing basis until further communication with me.

I agree to assume financial responsibility for all routine and emergency services rendered.

Please Initial the following statements

I have read and agreed to the above.

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The procedures have been explained to my satisfaction and I have all the information that I desire

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I have had the chance to ask questions.

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I am at least 18 years of age and I am the owner or authorized individual who is consenting to the performance of the procedures and to the administration of anesthesia.

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I give the doctor permission to ectract any tooth that is deemed necessary. (I am aware the price may vary depending on the tooth extracted.)

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Phone Number *

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Text message

Yes No

Emergency Number

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It is extremely important for owner, to be available to receive calls or text messages at all times, while the pet is hospitalized.

You will need to sign this document at the time of checking in at the hospital

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Crossroads Animal Hospital Procedure Consent Form

Please Indicate Your Choices Below

Microchipping is available while your pet is under anesthesia and is required for all City of El Paso animals over 4 months of age.

Heartworm testing and tick-borne disease screening is recommended annually for dogs that are not on the preventative or who are not on year-round preventative, and every 2 years for dogs on year-round preventative.

Feline Leukemia (FELV) and Feline Immunodeficiency Virus (FIV) testing is recommended for cats that have never been tested, kittens with unknown maternal vaccinations, or cats with outdoor exposure and not current on FELV vaccinations.

RISK DISLAMER FORM

Please Initial the following statements

It is extremely important for owner, to be available to receive calls or text messages at all times, while the pet is hospitalized.

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