Authorization for Surgery Form in El Dorado, KS

Fill out the Authorization for Surgery Form before your pet’s procedure at Bluestem Animal Clinic in El Dorado, Kansas. Completing this form ahead of time helps our team review important details, prepare for surgery day, and support a more efficient check-in process for dogs and cats.

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Authorization for Surgery Form

Please complete this form before your pet’s scheduled procedure at Bluestem Animal Clinic. Sharing this information in advance helps our team prepare for surgery, review instructions, and support a smoother experience on the day of your pet’s visit.

Phone # / Alt. Phone # (Where you can be reached today)
***ALL PETS MUST BE CURRENT ON VACCINATIONS AND FREE OF EXTERNAL PARASITES***
Any animal found to have fleas or ticks will be treated at the owner's expense
As the owner or agent of the above animal, I hereby give my consent to Bluestem Animal Clinic to perform the following procedure(s).
Laser surgery helps reduce pain by sealing nerve endings in the tissue, helps reduce bleeding by sealing the small blood vessels, and helps reduce swelling by not crushing, tearing or bruising the tissue. For elective procedures, please choose to either accept or decline having laser surgery by checking the appropriate box. An additional fee will apply.
Occasional problems can arise due to pre-existing conditions not evident during routine pre-anesthetic examinations. To avoid these problems, we recommend that all patients be screened prior to anesthesia by means of one of the following lab tests. Please choose ONLY ONE by checking the appropriate boxes. Please ask one of our staff members if you have any questions.
Preferred
While under anesthesia, Intravenous (IV) Fluids maintain blood flow and blood pressure to vital organs, speed recovery time from the anesthetic, and if surgical complications arise, we will already have access to the vein for the efficient and timely administration of medications. Please choose to either accept or decline the administration of IV Fluids by checking the appropriate box.
As the Owner / Agent of this pet, I have the authority to grant my consent and authorize the Doctors to treat, perform diagnostic tests, anesthetize and/or operate upon my pet. I understand that during the performance of this procedure, unforeseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above. I expect Bluestem Animal Clinic to use reasonable care and judgment in performing the procedure(s). The nature of the procedure(s) and risks involved has been explained to me and I realize the results cannot be guaranteed. I have been given the opportunity to ask the veterinarian questions regarding the procedure(s) and all questions have been answered to my satisfaction. I am also aware that unforeseen events resulting from the procedure(s) will not relieve me from any obligation to all costs incurred regarding the animal.
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