Anesthesia / Surgery Release Form

Name*

First NameLast Name

Pet's Name*

Breed*

Sex*

FemaleFemale, SpayedMaleMale, Neutered

Birthdate*

Date

I hereby authorize the Animal Hospital of Pensacola to perform the following procedure(s) and authorize the performance of other procedure(s) or operation(s) necessary and desired in the exercising of the veterinarian's professional judgment. I understand that I assume financial responsibility for all services rendered, and that payment in full is due when my pet is discharged. I understand and agree that all anesthesia and surgery involve a certain amount of risk to my pet. I further understand that results cannot be guaranteed and I will not hold the Animal Hospital of Pensacola liable. If any unforeseen medical or surgical needs arise, I hereby consent to any medications and supplies purchased or prescribed and understand that additional costs will be my responsibility.

***Our high standard of veterinary care includes: 1) pre-surgical physical exam, 2) ultra-safe human anesthesia, 3) IV catheterization, 4) monitoring of the heart rate and blood oxygen and 5) post-surgical exam.

If the event a situation arises where your pet may require resuscitation, do you authorize and accept financial responsibility for life support and CPR to be performed? Select one of the following:*

Yes, Life Support and CPRNo, Do Not Resuscitate

Pre-Anesthetic Lab Work - Select ONLY ONE*

Optimal Blood Profile - recommended for all pets, especially pets over 7 years of ageBasic Blood Profile - recommended for pets of all agesI, DECLINE all recommended Pre-Anesthetic Labs and understand and acknowledge the risks involved.

**Optional Services Available** - Our veterinarians advise the following services to further safeguard your pet from possible unforeseen problems. Please select for additional services desired.*

Laser Surgery - recommended for any surgery. Procedure is less painful, produces less bleeding.Post Procedure Laser Therapy - recommended to promote and speed the healing process.Microchip Insertion & Registration - recommended to identify your pet should they be lost.I, DECLINE all Optional Services Offered

Post-operative Pain Medication - We feel strongly about the need for appropriate pain management. The veterinarian will prescribe medication for extended relief of post-operative discomfort. I understand that I am responsible for any and all costs of post-operative pain management.

Signature*

Owner Signature REQUIRED

Today's Date*

Date

Contact Number for Today*

Area CodePhone Number

Emergency Contact Number*

Area CodePhone Number