Canine Surgical Release Form

Client Name *

First Name Last Name

Patient Name *

Procedure(s) to be performed: *

With any anesthetic procedure, there is always a risk of complications. Having a complete picture of what is happening within your pet decreases that risk.

For pets 7 years and older: we REQUIRE a blood panel before anesthesia.

For pets under 7 years: we HIGHLY RECOMMEND doing a blood panel before anesthesia.

**For convenience, bloodwork can be done one week prior or the day of your pet's procedure.

There are a variety of panels we can run for an additional fee, though our standard pre-operative panel focuses primarily on kidney and liver function, blood glucose, and is accompanied with a CBC to test for anemia and examine platelet count. We are also able to see if the pet is dehydrated and to what degree. One of our experienced technicians can talk you through the best choice for your pet.

*

Client's Initials

I request a preoperative blood screening with CBC or am interested in discussing it with my surgical technician. (Additional Fee) *

Yes No

An IV catheter is included in the procedure and will deliver fluids for hydration which will assist in maintaining blood pressure. It will also allow us to administer IV emergency drugs, if necessary. It does require us to shave a portion of fur at the catheter placement site.

I request the following additional services: *

Vaccinations (Additional Fee) Heartworm/Tick-Borne Disease Testing (Additional Fee) **We HIGHLY RECOMMEND this test. HomeAgain Microchip (Additional Fee) Deciduous Teeth Extraction (Additional Fee) Histopathology (Additional Fee) E-Collar (Additional Fee) No additional services at this time.

If dog is here for spay, when was last heat cycle? *

If deemed medically necessary, the Doctor will prescribe take home Pain Medication and/or Antibiotics with an additional fee. *

I request medication for post-operative sedation at home. (Additional Fee) I DO NOT want medication for post-operative sedation at home.

Recent Pet History (Vomiting, Diarrhea, Decreased Appetite, Increased/Decrease Water-Intake, Abnormal Behavior, etc.) : *

Is your pet allergic to any medications? If yes, which ones? *

Has your pet had previous seizures or other anesthetic problems? If yes, describe. *

Is your pet currently taking medications. Which ones? *

Owner Authorization and Release:

I understand that anesthesia and surgery always involves some risk to my pet (such as medication allergies, surgical complications, internal bleeding, shock, incision dehiscence, and post-surgical infections). I acknowledge that no guarantee or assurance has been made to me as to the results that may be obtained. In the event complications arise and I cannot be immediately contacted at the below listed phone numbers, Rathdrum Animal Clinic is directed to make the decision deemed best for my pet. I agree to pay for all services rendered at the time of discharge.

Signature *

Clear

Date *

Date

Best Number to Reach Someone on Day of Procedure: *

Area Code Phone Number

Is it okay to text this number? *

Yes No