Exotic Surgical Release Form

Exotic Surgical Release Form
Client Name

First NameLast Name
Patient Name
Procedure(s) to be performed:
I understand and acknowledge that several physiologic factors increase the risk of anesthesia in exotic animals.
Client Initials
I request the following additional services:
If deemed medically necessary, the Doctor will prescribe take home Pain Medication and/or Antibiotics with an additional fee.
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Best Number to Reach Someone on Day of Procedure:

Area CodePhone Number
Is it okay to text this number?
Should be Empty: