New Client Special – $25 off your first visit! Call for more details.

Mercer Island, WA

Anesthesia & Procedure Authorization Release Form

Please fill out this form before your visit. We can’t wait to meet you and your four-legged friend and look forward to the opportunity to serve you both for many years to come!

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Client's Name *

First

Last

Email *

Date *

Pet's Name *

Age *

Sex *

Male
Neutered Male
Female
Spayed Female

Procedure(s)

The time of my pet’s last meal was: *

Date

Time

The time of my pet’s last medication administration was:

Date

Time

Medications:

FVRCP Vaccine Due Date

Rabies Vaccine Due Date

FELV Vaccine Due Date

Would you like us to update vaccines? *

Yes, please update
No

WE REQUIRE A PREANESTHETIC BLOOD PANEL FOR ANY CAT OVER 7 YEARS OLD.

Your cat will be going under general anesthesia today. While we don't anticipate any problems, there are always risks involved with anesthesia. In order to recognize abnormalities that may change anesthetic protocols or indicate a need to postpone the procedure; your cat may need a pre-anesthetic blood panel. If any significant abnormalities are found, Island Cats will call you prior to anesthesia.

Please select: *

Due to your cat's age (7 years or older) preanesthetic blood is REQUIRED for this procedure.
Yes, I want my cat to have a preanesthetic blood panel.
No, I do not want my cat to have a preanesthetic panel prior to anesthesia. My cat is under years of age and I accept the potential risk involved.
I am not sure. I authorize the doctor to do a preanesthetic blood panel at his / hers discretion.
Patient has recently had a blood panel done.

For Dental Procedures Only:

Please extract any teeth that are medically advised (the price for extraction per tooth can vary from $80-$300 depending on difficulty and additional medication to go home).
Please call prior to dental extractions. I understand if the staff is unable to reach me in a timely manner, no extraction will be performed and another procedure may be required.

In Case of an Emergency: *

I authorize any necessary life saving care in the event of an emergency.
I do not want any life saving procedures in the event of an emergency.

I certify that I am the owner, or authorized agent for the owner, of the above animal. I hereby consent to and authorize the doctors and staff at this veterinary practice to admit this pet, perform the above described procedures, and administer medications, anesthesia, surgical procedures, tests and or treatments that the doctors deem necessary for its health, safety and well being while under their care and supervision. I have been advised of the nature of the procedures and the potential risks and benefits. I understand that veterinary medicine is an inexact science and that no guarantee of successful treatment can be made. *

I have read and certify.

I acknowledge that I am responsible for payment in full for the above procedures and treatments at the time my pet is discharged. *

I have read and acknowledge.

Signature *

Clear Signature

Phone *

New Client Special – $25 off your first visit! Call for more details.

Mercer Island, WA

Anesthesia & Procedure Authorization Release Form

WE REQUIRE A PREANESTHETIC BLOOD PANEL FOR ANY CAT OVER 7 YEARS OLD.

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