Surgical Release Form
If you have a surgery scheduled with us, please complete this form prior to your pet's surgery day. We will follow up for a deposit, if we have not already.
Owner's Name:
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First Name
Last Name
Owner's Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet's Name:
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I authorize this hospital to perform the below mentioned medical procedure(s) required for the diagnosis and treatment of my pet.
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Spay
Neuter
Mass Removal
Cystotomy
Gastrotomy
Splenectomy
Enterotomy
Dental
Enucleation
Aural Hematoma
Sedated Exam/Diagnostics
Amputation
Other
If other, please list the procedure.
I authorize the use of appropriate anesthesia and other medications as needed. I understand that during the performance of the above listed treatment/procedure(s), unforseen conditions may be revealed that necessitate an extension of the procedure(s), or different procedure(s), than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian's professional judgement and the animal's best interest.
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Initial Here
I authorize the use of appropriate anesthesia and other medications as needed. I understand that during the performance of the above listed treatment/procedure(s), unforseen conditions may be revealed that necessitate an extension of the procedure(s), or different procedure(s), than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian's professional judgement and the animal's best interest.
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Initial Here
I authorize the use of appropriate anesthesia and other medications as needed. I understand that during the performance of the above listed treatment/procedure(s), unforseen conditions may be revealed that necessitate an extension of the procedure(s), or different procedure(s), than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian's professional judgement and the animal's best interest.
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Initial Here
I understand that I can terminate treatment at any time by contacting the attending veterinarian. I also understand the staff of AHDC will follow all responsible precautions against illness, injury, or escape of my pet(s), but they will not be held liable or responsible in any manner whatsoever, under any circumstances, on account of the care, treatment, or safe keeping of my pet(s), as it is thoroughly understood that I assume all risks.
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Initial Here
I understand that any anesthetic or sedative poses some risks to the patient and that precautions will be taken to minimize such risks. Unfortunately, in some cases, your pet's condition may decline to a point where a decision must be made whether or not to perform cardiopulmonary resuscitations (CPR). I have been advised as to the nature of the procedure(s) and the risks involved. I realize that results cannot be guaranteed and that my financial obligation remains regardless of the outcome.
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Initial Here
All animals entering the hospital must be current on vaccinations and free of external parasites or they will be treated at the owner's expense. I agree to pick up my pet within five (5) days of the discharge date, and my pet may be considered abandoned if I do not pick up my pet within those five (5) days. In my failure to recover my pet, the hospital is authorized to take the appropriate action as deemed professionally necessary.
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Initial Here
I understand that AHDC is not a 24 hour care facility. The hospital is not staffed with medical personnel between the hours of 9:00pm-7:00am. If my pet is determined to be in critical condition, I will be provided with options that will ensure proper care is provided to my pet during these times.
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Initial Here
The doctors and staff will do their best to keep me updated on my costs should they extend beyond the scope of the estimate, but it is my responsibility to request updates should the treatment plan change. Full payment is due upon release of the pet. Pets are released only during regular office hours.
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Initial Here
Telephone number where the owner can be reached during the time of procedure:
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Please enter a valid phone number.
Would you like your pet microchipped as a means of permanent identification?
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Yes
No
Would you like your pet to have post-operative low level laser therapy to decrease inflammation and support healing?
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Yes
No
Is your pet on any medications, including aspirin? If yes, please list the medication(s) and dosing.
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If none, please type "N/A".
Has your pet been drinking and eating normally lately?
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Yes
No
Has your pet had any recent weight changes?
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Yes
No
Has your pet had any previous anesthesia (including at other clinics)?
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Yes
No
If yes, does your pet experience any problems?
Yes
No
Would you like CPR to be performed on your pet?
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Yes
No
Pre-surgery instructions
Please withhold food after 10:00pm the night before your pet's procedure. Continue medications as directed by the doctor.
Owner's Signature:
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Clear
Date:
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Month
/
Day
Year
Date
Submit
Should be Empty: