Owner *

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Patient: *

Color: *

Sex: *

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Date of Birth: *

Main Reason For Admittance: *

I hereby authorize and direct the veterinarians of Central Kentucky Veterinary Services to perform the procedures and additional diagnostic and/or treatment procedures as deemed advisable for my pet. The procedure(s) has/have been explained to me and no guarantee has been made as to the results or cure. I understand that there may be risks involved in some of these procedures.

I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Any estimates or charges for the planned procedures are only approximations, and the final bill may be greater or less than these amounts. All services must be paid for when released. Some procedures require a deposit to be made before surgery.

Like you, our greatest concern is the well-being of your pet. A physical examination will be performed before anesthetizing your pet. However, many conditions including disorders of the kidneys, liver, heart & blood cannot be detected without blood lab screening. For this reason, we highly recommend pre-operative screening before sedating your pet. Please mark the appropriate options below:

Please Pick One *

I DO authorize the recommended Pre-surgical Blood Screen. The cost is $72.47 if done prior to the day of surgery.
I DO NOT authorize the recommended Pre-surgical Blood Screen. I understand and assume all responsibility for additional risks/complications resulting from refusal to approve this blood screening for my pet’s safety.

I would like my pet to have pain relief medication dispensed to use at home.** *

Yes
No

Are vaccinations and laboratory tests current today (within the last year)? *

Yes
No

Did your pet eat this morning? *

Yes
No

List any medications your pet is taking and the time of last dose.

Elective Procedure to be done while your pet is anesthetized (please check):

**Items marked with asterisk are at an additional charge & not included in the price of the surgery

Please List: *

Other Requested Procedures** *

At Central Kentucky Veterinary Services, our greatest concern is the well-being of your pet. Your pet is scheduled for an anesthetic procedure. Before putting your pet under anesthesia, we routinely perform a full physical examination. In order to maximize patient safety, we highly recommend, and sometimes require, a pre-anesthetic blood profile. The surgeon may be alerted to the presence of certain conditions that could complicate the procedure, such as dehydration, anemia, infection, diabetes, and/or kidney or liver disease. These tests are similar to what your own physician would conduct prior to you undergoing anesthesia and help ensure the administration of the most appropriate anesthetic regime. *

The Quantitative Blood Count (QBC) and Pre-Anesthetic Profile which includes: CBC (PCV (anemia), white blood cell count (infection) and red blood cell count (anemia/bleeding disorder), platelet count (clotting disorder)) and Chemistry Profile (BUN and creatinine (kidney), ALKP and ALT (liver), glucose (sugar), total protein (dehydration), and electrolytes (imbalance)).
The owner elects to decline the recommended pre-anesthetic blood tests at this time but requests that we proceed with the procedure.

Other tests are available that are not included in the above choices. The tests selected above give the doctor a suitable overview of healthy patients. For those patients who are sick or in their senior years (above the age of 9), a full senior profile can be performed the day of the procedure with the doctor’s recommendation or at the owner’s request.

Our ability to minimize anesthetic and surgical risks and maximize patient safety is greatly enhanced by the completion of a physical examination and blood work prior to a surgical procedure. If you have any questions or concerns about the scheduled procedure, please do not hesitate to call or email at 859-987-6721 / customerservice@centralkyvet.com to discuss any aspect of the upcoming procedure.

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Online Forms

Anesthesia Consent Form

Online Forms

Anesthesia Consent Form

Anesthesia Consent Form

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