Exotic Surgical Release Form

Client Name *

First Name Last 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: *

HomeAgain Microchip (Additional Fee) E-Collar (Additional Fee) Histopathology (Additional Fee) No additional services at this time.

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 *

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