Anesthesia, Surgical, and Medical Release

Client's Name:*

Pet's Name:*

Please select type of procedure(s) being performed:*

Date of Procedure: *

Date

When did your pet last eat? (Date and time)*

List all medications your pet is currently receiving*

Has your pet ever had a seizure? If yes, when?

Has your pet ever had previous anesthetic complications? If yes, please describe.*

We require pre-anesthetic blood testing for ALL animals that will undergo surgery. The type of test is determined by the age, health status of pet, and type of procedure. For a healthy pet, the standard categories are as follows:

Spay/Neuter for pets 2 years of age or younger:
· Canines and Felines: Basic Chemistry/CBC/Pt/Ptt sent to outside lab within a 4-week period prior to procedure, and a PCV completed day of procedure. If pre-op bloodwork was not performed prior, than a basic chemistry (pre-surgical panel) and CBC will be ran in house. For felines, a Pro-BNP will also be performed day of procedure.
Surgical Procedure for ages 2-7 years (includes elective and non-elective - spay/neuters, dentals, mass removals, orthopedic procedures, etc.)
· Canines: Superchem/CBC or wellness panel (at annual wellness exam) sent to outside lab within a 4-week period prior to procedure, and PCV completed day of procedure. If pre-op bloodwork was not performed prior, then a Chem 17 / CBC / Lytes will be ran in house.
· Felines: Superchem/CBC or wellness panel (at annual wellness exam) sent to outside lab within a 4-week period prior to procedure, and PCV / pro-BNP completed day of procedure. If pre-op bloodwork was not performed prior, then a Chem 17/CBC/Lytes/pro-BNP will be ran in house.
Surgical Procedure for Ages 7+ (inclueds elective and non-elective procedures):
· Canines: Superchem/CBC/T4 or wellness panel (at annual wellness exam) sent to outside lab within a 4-week period prior to procedure, and PCV completed day of procedure. If pre-op bloodwork was not performed prior, then a Chem 17 / CBC / Lytes / T4 will be ran in house.
· Felines: Superchem/CBC/T4 or wellness panel (at annual wellness exam) sent to outside lab within a 4-week period prior to procedure, and PCV / pro-BNP completed day of procedure. If pre-op bloodwork was not performed prior, then a Chem 17/CBC/Lytes/T4/pro-BNP will be ran in house.

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.*

Would you like to have your pet microchipped while under anesthesia? The cost for this service is $87.50 and includes the price of chip implantation, one-time activation fee, and first year's membership fee.*

Yes, I would like my pet microchipped todayNo, thank you

Certificates for spay/neuters must be presented upon admission. Will you be providing a certificate for surgery? If using a certificate, please be aware that the certificate does not cover costs of pre-anesthetic exam, bloodwork, or medications.*

Yes, I will be providing a certificate at drop offNo, I do not have a certificate

For Pets Undergoing a Surgical Procedure: Draw on Image

Additional Comments:

For Pets Undergoing a Dental Procedure

Signs of oral and dental disease in dogs and cats include bad breath, loose or discolored teeth, mobile teeth, drooling, dropping food, and bleeding from the mouth. Oral and dental disease can be painful for your pet and compromise their overall health.

Animals will be anesthetized during their dental procedure to allow for a complete and thorough oral examination and professional cleaning. All patients undergoing a dental procedure will have a complete oral exam, a thorough scaling of teeth to remove tartar and plaque, and polishing of teeth to remove any scratches and to slow down the rate of attachment of bacteria to the crown.

During the dental examination, the veterinarian may identify various dental conditions or concerns that could not be identified beforehand, such as broken or abscessed teeth, bone loss, deep pocketing, etc. These problems may require additional procedures beyond routine dental cleaning. These additional services may include dental radiographs, tooth extractions, periodontal therapies or application of antibiotic gel or sealants. As these services are necessary on a case-by-case basis, they will incur an additional cost that may not have been included in the routine dental cleaning estimate. These problems are best addressed while your pet is under anesthesia.

If the veterinarian feels that further services are necessary, we will make every effort to contact you. As these findings are often not known until
the pet has been anesthetized, we will continue with the procedure as notated below for the safety of the animal.

Please notate below how you would like us to proceed with the dental procedure if we are unable to contact you in a timely manner while your pet is anesthetized:

I authorize the veterinarian to proceed with any necessary treatment for my pet, regardless of the costI authorize the veterinarian to proceed with any necessary treatment for my pet, up to a certain dollar amountI do not authorize the veterinarian to proceed with additional treatment without my consent. I understand that if I am unable to be reached by phone, my pet will be recovered from anesthesia and an additional anesthetic procedure will be needed to address the problem, which will result in an additional cost

Please notate the dollar amount authorized to proceed with additional dental treatment(s).

I, the undersigned, certify that I am the owner, or 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 understand that if my pet has a known or suspected heart condition, preoperative radiographs and echocardiogram may be required. 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. 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.

Phone number where we can reach you today*

Please enter a valid phone number.

Signature*

Date Signed*

Date