Surgical / General Anaesthetic Consent Form Payment Agreement
Client:________________________________ Contact No:________________________________
Pet Name:_____________________________ Nature of Procedure:________________________
Please read carefully the information below and sign.
Your pet is in the clinic today for anaesthesia/surgery. We will perform a full physical examination on your pet before administering the anaesthesia. However, there are inherent risks to surgery and this is why we highly recommend a pre-anaesthetic blood test to be performed. This can reduce the risk and help us rule out any pre-existing internal problems that may not be evident physically, but could lead to serious complications.
Healthy patients under 8 years of age Cost: $71.55
Includes: BUN (Kidney) - ALKP (Liver) – Glucose (Sugar) – Total Protein (Hydration) – ALT (Liver) – Creatinine (Kidney) – Complete Blood Count (Anaemia, infection, clotting)
Geriatric patients/ Sick patients Cost: $111.10
Includes: All tests in the healthy animal profile, plus – Albumin (Protein) – Phosphorous (Kidney) - Calcium (Tumors) – Total Bilirubin (Liver) – Amylase (Pancreas) – Cholesterol
YES I want you to perform the recommended pre-anaesthetic blood test prior to surgery on my pet.
NO I do not want you to perform the pre-anaesthetic blood test prior to surgery on my pet.
Does your pet need any other treatments today?
Vaccination Heartworm preventative Intestinal worm preventative Microchip
Estimate of surgery/procedure cost: $________________________________________________

I understand that no surgical or anaesthetic procedure is without some risk to the patient, regardless of age or health of the patient. Having been made aware of these risks, I give my consent for the surgical/anaesthetic procedure to be performed on the animal described above.
I understand that the estimated costs of the procedure can change due to unforeseen circumstances that can arise during any procedure and agree to pay any fees in relation to the above animal in full at the time of collection.

Signature of Owner or Responsible Agent:________________________________________
Date:____________________
John the Vet, Bentleigh Dedicated to improving the quality of life of all creatures great and small