Macon County Veterinary Hospital Anesthesia/Surgical Release Form

Macon County Veterinary Hospital Anesthesia/Surgical Release Form
Date*
Procedure (example: Spay, Neuter, Dental, Mass Removal, Sedation Nail Trim or Groom)*
Pet Parent Name*

First NameLast Name
Patient Name*
Best Phone Number to reach you at with updates*
Please enter a valid phone number.
Would you prefer us to contact you by*

TextPhone Call
Has your pet eaten this morning?*

YesNo
Has your pet had any coughing, sneezing, vomiting or diarrhea?*

YesNo
If your pet has retained baby teeth, can we extract them? It is recommended that the baby teeth be removed if they have not fallen out and the adult teeth have come in.*

YesNo
If your pet is having a Dental Cleaning, may we extract any necessary teeth?*

YesNo
If you pet is having a mass removed, do you want the mass biopsied?*

YesNo
Would you like your pet microchipped while under sedation?*

YesNo
Would you like the RECOMMENDED PRE-ANESTHETIC BLOODWOORK. Under 3 years of age (CBC ONLY). Over 3 years of age (CBC, CHEMISTRY 17 & ELECTROLYTES)*

YesNo
I UNDERSTAND THAT THERE ARE ALWAYS RISKS INVOLVED WITH ANESTHESIA. IF A MEDICAL EMERGENCY ARISES
THE DOCTORS OF MACON COUNTY VETERINARY HOSPITAL WILL DO EVERYTHING POSSIBLE TO SAVE MY PET. I
UNDERSTAND THAT ALL CHARGES MUST BE PAID AT THE TIME OF PATIENT RELEASE. IN ORDER TO MAINTAIN A
DISEASE FREE ENVIRONMENT, YOUR PET MUST BE FREE OF INTERNAL AND EXTERNAL PARASITES. IF YOUR PET IS
INFECTED, THEY WILL BE TREATED AT YOUR EXPENSE.
Signature*

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