Anesthetic and Surgical Release Form

Client Name

First NameLast Name

Patient Name

Admission Date

Date

Doctor Name

Performing surgery

Procedure being performed

Phone Number

Best contact number for today.

Please Note: It is important that you can be reached today at the number(s) you’ve provided so that the doctor can discuss any health concerns regarding your pet or in case of emergency. If you cannot be reached, our doctors will make any necessary medical or surgical decisions that they feel is in the best interest of your pet.

Patient comfort and effective pain management are top priorities at our hospital. Patients that receive analgesic medications are less anxious, have decreased anesthetic risk, and recover from procedures more rapidly. Our doctors strongly recommend pain management for most surgical and dental procedures. Please ask us if you have any specific questions regarding post-operative pain control.

I, the undersigned, certify that I am the owner, or authorized agent for the owner of the above mentioned pet, and I authorize the doctor on duty and technicians to perform the procedures listed above, including administration of sedatives, and/or anesthetics, as well as any appropriate medical, diagnostic and/or emergency care for my pet.

Initials*

I authorize the above listed procedures. I have been advised as to the nature of the procedure(s) and the potential risks. I also understand that no guarantee of successful treatment can be made. I have read and understand the reasons for and the risks of the above procedure(s), and assume full financial responsibility for all services and charges incurred. I have been provided with an estimate for services and do approve this plan. I understand that this estimate could vary based on the needs of my pet at the time of surgery/anesthesia. I understand that in the event of any significant changes to the treatment plan the doctor will attempt to contact me at the number(s) provided above, but if no contact is made the doctor will use his/her judgment to determine the best care for my pet. Brighton-Eggert Animal Clinic is NOT a 24-hour facility. In the event that it is necessary to hospitalize your pet overnight, he/she will be attended to as necessitated by his/her condition as judged by the attending veterinarian.

Our doctors use the safest anesthetic and surgical protocols available for our patients. However, no anesthetic or surgical procedure is completely without risk. Complications may range from mild nausea to prolonged recovery, and in rare cirucmstances, even death. Preanesthetic bloodwork testing helps to idenify many clinically silent conditions that may pose an unusual anesthetic risk for the apparently healthy patient. If more extensive testing is recommended, this will be discussed by the doctor.

In the unlikely event my pet experiences a cardiac, respiratory or other life-threatening emergency that requires resuscitative or other urgent care measures, such as cardiopulmonary resuscitation (CPR), positive pressure ventilation, emergency drugs, or other similar measures, I request that the veterinarians and/or trained staff at Brighton-Eggert Animal Clinic pursue such medical care as indicated below; Please initial one of the directives listed below:

Must pick one:*

Resuscitate (R): I authorize emergency treatment if the situation arises (including cardio pulmonary resuscitation (CPR) and other life-saving treatments) and understand this may result in additional charges and I agree to pay for these emergency and life-stabilizing treatments even if they exceed any estimate I may have been provided. I understand that despite the best efforts of the veterinarians and staff, any emergency treatment, including CPR does not guarantee or assure a favorable outcome for my pet.Do Not Resuscitate (DNR): I do NOT authorize emergency treatment if the situation arises (including cardio pulmonary resuscitation (CPR) and other life-saving treatments) and prefer to be contacted before any additional treatment is performed. I understand that requiring a call before treatment may delay treatment and may affect the outcome. I understand that despite the best efforts of the veterinarians and staff, any emergency treatment, including CPR does not guarantee or assure a favorable outcome for my pet.

PAYMENT IN FULL IS REQUIRED AT THE TIME OF DISCHARGE FROM THE HOSPITAL.

Signature*

Date*

Date