Surgery release form

Medical History
Has your pet been diagnosed with a medical condition ? (Example: heart murmur, epilepsy, Cushings, diabetes)*

YesNo
Please list all medical conditions *
Is your pet being treated by another veterinary clinic?*

YesNo
please list any clinics we may need to request records from
is your pet currently taking any medications, vitamins or supplements ?*

YesNo
Please list all medications or supplements you pet is taking. Please include dose, frequency, and when last dose was given *
Please contact our office prior to surgery for instructions on how to proceed with your pet's medications prior to your surgery appointments

call or text 801-269-1213
Is your pet allergic to any medications*

NoYes
please list any medications your pet is allergic to*

Owner Consent for CPR or DNR
CPR- Cardio Pulmonary Resuscitation is the treatment provided for a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet who has stopped breathing (but still has a heartbeat) is more likely to be successful than a pet who has no heartbeat.

DNR- Do Not Resuscitate means that if a pet stops breathing or his/her heart has stopped, no effort should be made by our veterinary professionals to attempt to revive the pet, and the pet will be allowed to die.
IN THE EVENT OF A MEDICAL CRISIS*

I wish for the doctors and the staff at Midvalley Animal Clinic to perform CPR on my pet if he/she suffers respiratory or cardiac arrest. I understand that my pet may or may not respond to this life-saving procedure. I understand that if my pet survives because of CPR, he/she may have permanent health issues. I understand and accept full financial responsibility for the cost of CPR and understand it may cost up to $800.00.I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing, and/or his/her heart stops beating, my pet will die. I elect to have DNR orders placed on my pet’s record

Possible additional charges
- We give an injection of pain meds with every surgery.
- We will be sending home oral pain medications. The doctor may also send home a Elizabethan collar to prevent infection and ensure your pet cannot lick or damage the surgical site. We also have recovery shirts available as an alternative to the Elizabethan collar. (Recovery shirts do not protect feline neuter incisions)
- Your pet may also require a bandage or additional medication.
If needed

I would prefer to use a recovery shirt if possible. I understand this would be an additional fee. ( Average $30-$35)I would prefer to use an Elizabethan collar.
Please choose one

I would like to add Nocita as additional pain control. I understand this will be an additional cost. typical is $30-$45 based on the size of my pet. larger incisions like amputations may be up to $130. Nocita is not recommended for lumps that are suspected of being malignant (Cancer).I decline the local anesthetic
PAIN MANAGMENT - We are now offering a local anesthetic (numbing medication). This medication is used to numb the incision site for 3 days to help reduce pain or discomfort.
I understand these charges may not have been in any quote or estimate given.*
please initial
Nausea and added Pain

Anesthesia and pain can cause nausea. We have an injectable medication that can be given to your pet to help with these side effects called Cerenia. This injection will provide relief for 24 hours. The price for this injection is based on size.

10lbs	$29
20lbs	$37
30lb	$45
40lbs	$54
50lbs	$62
60lbs	$70
70lbs	$78
80lbs	$86
90lbs	$95
100lbs	$103

Would you like your pet to have a a Cerenia injection for nausea and pain?
I understand if an estimate of charges was given, the estimate is only an approximation and that unforeseen circumstances may result in final charges substantially greater than the estimate.*
please initial

Authorization and acknowledgement of risk
I am the owner, or authorized agent of the owner of the pet presented for care

I have been advised of the nature of the procedure mentioned above and the risks involved in performing these procedures. I hereby and forever release the doctors and staff at Midvalley Animal Clinic of Taylorsville, Utah from any liability arising from anesthesia and surgery on the aforementioned animal.
I understand all fees for services rendered are payable by cash, check, or credit card at the time services are rendered. I used understand any past due accounts are subject to all costs of collection, including legal fees.*
please initial
I authorize Midvalley Animal Clinic to do the preceding services on my pet. I understand the following (1) No guarantee of successful outcome of treatment is either expressed or implied. (2) Risks are involved in the treatment of any condition including death.*
please initial
I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge,I also certify that;
- I understand the questions and statements on this form.
- I have read and understand the information. I understand the risks for giving false information
- I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
Client name (print).*
Signature*

Clear
Todays date*

MonthDayYear
Date
Are you leaving any items with your pet? (Example: blanket, toy, leash, carrier)
please be aware all items left may become soiled
Should be Empty:

Surgery Release

Lump Removal - The Veterinarian will only remove masses that are marked on your pet and in this document.

Medical History

Owner Consent for CPR or DNR

Nausea and added Pain

Authorization and acknowledgement of risk