Pre-Anesthesia Form "*" indicates required fields Client Name* First Last Date* MM slash DD slash YYYY Pet's Name* Procedure to be performed* The above mentioned pet is scheduled for an anesthetic procedure today. While we use the safest anesthesia available, no anesthesia is without risk. Prior to anesthetizing your pet, the doctor will perform an examination to identify any obvious reasons to forego the scheduled surgical procedure. However, many health concerns may go undetected without routine blood work being performed. It is of up most importance to first identify any underlying medical conditions that may possibly impact medical or surgical protocols chosen by the doctor. The results of the test serve as a reference baseline to compare against any future blood work. If any fleas are present, your pet will be treated in house accordingly. NOTE: Pre-surgical testing/blood work is strongly recommended for patients 7 years and older. A heartworm test is strongly recommended for any patients that have not been on a monthly heartworm preventative, and is greater than 7 months of age. Felines Only Leukemia/FIV Combo Test - $47 Yes No Patients under 7 years of age: Pre-Anesthesia Blood Work - $140 Yes No Senior patients 7 years and older: Pre-Anesthesia Blood Work - $160 Yes No Pre-Anesthesia Blood Work: Determination of the safety of drugs used for pre-surgical medication as well as any that may be used post-operatively. Identify unseen disease. Provides surgical peace of mind. Establish health baseline values. Evaluate your pet’s ability to remove the by-products of the anesthetic medication from the body. Heartworm Test (If your dog is over 7 months old; Has not had a negative test result within the last Year, and/or has not been on a monthly preventative) - $26 Yes No Rescue Microchip (Includes registration) - $45 Yes No My signature indicates that I have read this authorization, and understand the risk involved with putting my pet under anesthesia. I give my consent to Blanco Veterinary Clinic to perform the above mentioned procedure and pre-anesthetic screening, as directed above. Signature*Daytime Phone Number*NameThis field is for validation purposes and should be left unchanged.