Anesthesia, Surgical, & Medical Release

Owner*

Date

Pet's Name*

Sex

Age

Indicate years, months, weeks

Breed

Color

Procedure(s) Being Performed Today

List any medications your pet is currently taking (including vitamins and supplements):

When did your pet last eat? (Time/Day)

Has your pet ever had a seizure? (When)

Has your pet had previous anesthetic complications? (Please describe)

I, the undersigned, certify that I am the owner, or an authorized agent for the owner, of the above-described animal. I authorize the doctor on duty and assistants to perform the procedures listed above, including the administration of pain relief medications, sedatives, and/or anesthetics, as well as any necessary and appropriate medical, radiology, surgical, nursing, diagnostic, and/or emergency care for the animal. I have been advised as to the nature of the procedures and the potential risks and understand that no guarantee of successful treatment can be made. I have been informed and am clear in my understanding of the fees associated with services to be performed.

All surgery patients are administered pain injections. Spay/neuter certificates do not cover the cost of these injections; they will be the responsibility of the owner. (Cost is approximately $30.00-$40.00). Pain injections will be administered at the discretion of the doctor.

I have read and understand the reasons for and the risks of the above and attached authorized procedure(s), and assume full responsibility for all charges and services incurred to the described animal. I understand that in the event of anesthetic complications or if emergency medications must be administered, additional charges could be incurred.

Signature*

Clear

Emergency Contact Name*

Phone numbers where we can reach you today*

	Phone Number
Work
Home
Cell

Would you like to have your pet microchipped while under anesthesia? Your cost is $82.50. This includes the price of chip implantation, one-time activation fee, and first year's membership fee.*

YesNo

Certificates for spay/neuters must be presented upon admission. Are you using one today?

Yes*No

We require pre-anesthetic blood testing for ALL animals that will undergo surgery.

The type of test is determined by the age and health status of the pet. For a healthy pet, the standard categories are as follows:

All Pets 0-3 years: Basic chemistry profile for organ function screening, packed cell volume, and total solids, done in-house, included in the cost of a routine spay or neuter.
*If using a certificate, there will be an additonal cost of $40.00 (required for the safety of your pet undergoing anesthesia).

All Pets 3 years and over: Complete blood count and serum chemistry profile, sent to an outside lab within 30 days of the procedure date. If blood testing has not been performed within 30 days of the procedure, an in-house profile will be performed and incur a charge of $206.00.

Felines Only (All Ages): A proBNP test to evaluate proper heart function for felines is required prior to surgery. This test will be performed day of procedure and will incur a charge of $37.50.

I have read and understand that my pet is to receive the necessary pre-anesthetic blood testing dependent on his/her age, health status, and/or doctor recommendation.*

Clear