Surgical Release

Owner*

First NameLast Name

Patients Name*

Is your pet allergic to any medications?*

If yes please specify

Has your pet had any illness or injury in the past 30 days?*

If yes explain

Does your pet have seizures?*

Has your pet had any previous anesthetic problems? *

If yes explain

Is your pet currently on any medications? Please list here:

Please select procedure/procedures to be Performed

If procedure is not listed please specify.

Elective procedures to be done at the same time

Ear cleaning $5Routine Nail Trim FreeExtract retained baby teeth $25 eachLaser Wart removal 1st $50, each additional $25.

Pre-Surgical Bloodwork:*

I give permission for pre-anesthetic blood screening (cost, $75).I do not give permission for pre-anesthetic blood screening. I understand that I assume all responsibility for any risk/complications resulting from my refusal of this service. I understand that if blood screening is not elected the veterinarian has the option of declining surgery based upon age and quality of my pet’s health.

Blood Pressure Monitoring: *

I give permission for blood pressure monitoring for my pet at the cost of $30I do not give permission for blood pressure monitoring and I understand that I assume all responsibility for additional risk/complication resulting from my refusal of this service.

EKG read by Cardiologist:*

I give permission for my pet to receive a pre anesthetic EKG prior to surgery at the cost of $30.I do not give permission for my pet to receive a pre anesthetic EKG. I understand that I assume all responsibility for additional risk/complication resulting from my refusal of this service.

Therapy Laser *

I do authorize Post surgical Therapy Laser Treatment at the cost of $10.I do not authorize Post surgical Therapy Laser Treatment.

Laser/Electrocautery: *

Yes, I want my pet to have laser/electrocautery surgery and understand the costs are in addition to normal surgery costs.No, I decline laser/electrocautery surgery for my pet.

I understand that anesthesia carries inherent risks. These risks have been explained to me, and all my questions have been answered. I agree to hold Surf City Pet Hospital and its doctors and technicians harmless for complications (in the absence of negligence) in connection with these procedures. In the event that complications arise and I cannot be immediately contacted at the phone number listed below, I direct my veterinarian to make the decision he/she deems best for my pet.

I have read the foregoing, understand what it says, and agree. *

Emergency phone number where you can be reached today:*

Area CodePhone Number