Client's Name *

First

Last

Email *

Patient's Name

Breed

Emergency Contact Phone *

Species

Canine
Feline

Sex

Male
Female

I am the owner or agent for the above described pet and have authority to execute this consent. I hereby consent and authorize the performance of the following procedure(s) or operations(s): *

I understand that during the performance of the foregoing procedure(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedures(s) or operations(s) or different procedure(s) or operations(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are necessary and desirable in the exercise of the veterinarian's professional judgment.
If a dental is performed, extractions are only done, if a tooth cannot be salvaged otherwise.
I also authorize the use of appropriate anesthetics, and other medications, and I understand that hospital support personnel will be employed as deemed necessary by the veterinarians.
I have been advised as to the nature of the procedure(s) or operation(s) and the inherent risks involved with anesthesia. I realize that results cannot be guaranteed.

I understand that in order to add to the safety of anesthesia to my pet, a pre anesthetic health profile should be performed prior to surgery under anesthesia. If i should utilize these safeguards, i realize that it will increase my bill accordingly as seen below: (please initial.) *

In addition, pain medication may be prescribed by the veterinarian to manage your pet's condition at home.

Pre anesthetic blood profile

I give my permission for a Pre Anesthetic Blood Profile. (Recommended for pets 8 years of age and older)—$71.50
I decline the Pre Anesthetic Blood Profile

Microchip insertion

I would like the Microchip insertion—$54.00
I decline the Microchip Insertion

Puppy or kitten - teeth

I give my permission to remove any retained baby teeth at a charge of $19.00 per tooth.
I decline to remove any retained baby teeth.

IV Fluids

If the doctor deems it necessary, I give my permission for IV fluids to be administered—$73.50

I would like pain medication for my pet post surgery.

Yes
No

Would you prefer liquid or pill for go home medication?

Liquid
Pill

I would like a histopath sent to us for an additional $196.00

Yes
No

I have read and understand this authorization and consent.

Signature

Clear Signature

Surgery Release Form

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