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Surgery Authorization - Powell Animal Hospital - Powell, TN

Powell Animal Hospital

205 Star Mountain Way (Formerly500 W Emory Rd)
Powell, TN 37849

(865)938-1884

powellanimalhospital.com

Surgery Authorization

Name (required)
First Name (required)
Last Name (required)
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Street Address (required)
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State / Province (required)
Zip / Postal Code (required)
Phone number where you can be reached: (required)
Phone TypePhone Number (required)
Alternate phone number:
Phone TypePhone Number
Emergency contact in case you cannot be reached at above numbers
Phone TypePhone Number
E-Mail Address (required) :
Pet's Name (required)

Surgical Procedure (i.e. spay, neuter, declaw, etc.) (required)

PRE-ANESTHETIC BLOOD EVALUATION:
We recommend that all patients admitted for surgery have a pre-anesthetic blood evaluation completed to screen for pre-existing internal problems that may not be evident physically, but could lead to potential anesthetic complications. Further testing may be recommended for some patients and this will be discussed with you by your veterinarian on a case-by-case basis. Additionally, for their safety, all animals over the age of 7 years are required to have pre-anesthetic blood testing prior to anesthesia. The price of this laboratory testing for animals under 7 is $85.50. If you bring them in a day or more before, you can elect an adult wellness with heartworm test for only $52.38 For animals seven and over a Senior Wellness with Urinalysis is recommended. This requires an extra day to send the samples out to the reference lab. Alternatively an in-house CBC & General Health Profile (GHP) may be done. The cost of the Senior Wellness is $121.27 or the CBC & GHP is $106.75. The Senior Wellness includes more thorough testing, as well as a thyroid hormone check and a urinalysis. The older the animal the more important this screening becomes.
Please indicate your selection below: (required)

Please complete the recommended bloodwork prior to surgery
I have elected to refuse the recommended pre-anesthetic bloodwork at this time (applicable for patients under 7-years-old only)


SURGICAL FLUIDS:
We recommend that all animals undergoing anesthesia receive intravenous fluids through an IV catheter during their procedure. This allows us to better control their blood pressure while under anesthesia. Additionallly, in the case of an emergency, an IV catheter makes it much easier to quickly administer life-saving medications. Once again, we require surgical fluids on all pets over the age of 6-years-old. The price for the administration of fluids during surgery is $60.07. All dentistry patients are required to have surgical fluids
Please indicate your selection below (required)

Please administer the recommended fluids to my animal during the surgical procedure (must be selected for all dentistry patients)
I have elected to refuse the recommended surgical fluids (applicable for patients under 7-years-old only)


MICROCHIPPING:
We like to offer microchipping to all of our patients while they are under anesthesia. During this procedure, a small chip is placed under your pet's skin. This chip contains a number which is then linked to your personal information such as your address and phone number. If your pet ever becomes lost and is brought to a veterinary clinic, animal shelter, or other animal facility, your pet will be scanned for a microchip which could help him find his way back to you! The cost of microchip placement, including activation of the chip, is $52.15.
Please indicate your selection below: (required)

I would like my pet to be microchipped while under anesthesia
I have decided to decline having a microchip placed during my pet's procedure


Authorization:
By submitting this form, I hereby authorize performance of the above surgical procedure. The nature of such service has been described to me to my satisfaction and I realize that no guarantee nor warranty can ethically or professionally be made regarding the results or cure. I understand that I assume financial responsibility for all services rendered, and that payment is due on the date of surgery.
I have read this statement and - (required)

I agree.
I disagree.



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