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 pets 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 of 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.CPR may cost up to $800.00I 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 as well as an Elizabethan collar to protect their incision.

Your pet may also require a bandage or additional medication.
I understand this charge will be an additional charge and may not have been in any quote or estimate given.*
please initial
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

Authorization and acknowledgement of risk