Auth for Surgery

FAMC Anesthesia Consent

* Indicates required field

Client Name *

First

Last

Pet's Name *

Procedure(s) to be performed: *

Is your pet current on vaccines? *

Yes No No, please update today.

Did your pet eat the day of surgery? *

No Yes

Any vomiting/diarrhea or coughing/sneezing *

No Yes

If yes, please explain: *

Any additional problems or procedures to address today: *

Please list all of your pet's medications, supplements and flea control *

Microchip Placement? (additional cost) *

Yes No No, my pet is already microchipped

PRE-SURGICAL BLOOD TESTING:
We strongly recommend that all pets undergoing anesthesia have blood work performed prior to any procedure. Blood work helps us to detect infection or anemia and to assess kidney and liver function. Information gained from these lab tests allows us to adjust each patient’s anesthetic protocol as needed. Please select your choice below.

Please select one: *

Routine pre-surgical blood profile (< 7yrs old) $109 Senior complete body function profile (>7yrs old) $145.00 I decline any blood work for my pet

All animals will receive a free nail trim while under anesthesia. If you decline be select below. *

Do NOT trim my pet's nails

If fleas or flea dirt are present on your pet, we will apply a quick acting Capstar flea treatment ($12.30).

I affirm that I am the owner or agent of the animal names above and I am over 18 years of age. My electronic name entry herein constitutes my legal signature and authorizes Fidalgo Animal Medical Center to perform the above procedures. I have been advised of the nature of the services and procedures to be performed, as well as the risks involved. I acknowledge that no guarantee or assurance has been made to me as to the result or cure. Should life-saving emergency care be needed, it will be performed unless discussed prior with your care team.

Name *

First

Last

Phone number for the doctor to call: *

Cell Number for Text Messages *

Vehicle make/model/color: *

Submit

FIDALGO ANIMAL MEDICAL CENTER

office hours

Monday 7:30 am to 5:30 pm
Tuesday 7:30 am to 5:30 pm
Wednesday 7:30 am to 5:30 pm
Thursday 7:30 am to 5:30 pm
Friday 7:30 am to 5:30 pm
Saturday 7:30 am to 5:30 pm
Sunday CLOSED

Request Appointment

In Case of Emergency

3303 Commercial Ave
Anacortes, WA 98221
FAMC@FIDALGOVETS.COM

Phone: (360) 293-2186

Text: (360) 328-7421

Fax: (360) 293-2187

Our Partners in care