Surgical Information Form

Surgical Release Form
Date

MonthDayYear
Date
Pet Name:
Your Name

First NameLast Name
Cell Phone*
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
How would you like us to let you know contact you after surgery?*
Email
example@example.com

Procedure and Details
DogCat
Surgery To be performed:*
YesNo
If we are doing a dental cleaning, and while your pet is under if we find teeth that should be extracted would you prefer:*
If other please specify/or any additional requests:
Any additional information or issues you would like addressed?
He is a love bug and likes his belly scratched!
Is there anything else you would like the doctor or techs to do while your pet is under anesthesia?

Waiver and Optionals Portion
YesNoDoes not apply/recently done
Pre-anesthetic / Pre-surgical Diagnostic Tests Waiver
*Only if declining pre-anesthetic bloodwork*
Our doctors use the safest anesthetic and surgical protocols available to minimize risk to your pet, however no anesthetic or surgical procedure is completely without risk.

I, the undersigned, am the owner or authorized agent of the pet named above. I have been offered pre-anesthetic labwork for my pet to evaluate organ function and blood cell counts prior to the administration of anesthesia.

I understand that:

1.) Pre-anesthetic labwork can help detect underlying health issues that may increase the risks of anesthesia.
2.) Declining these tests may mean potential issues remain unidentified.
3.) No procedure is without risk, and by declining these tests, I may increase the potential risk to my pet.
4.)Knowing these risks, I hereby decline the recommended pre-anesthetic labwork and release Hearthstone Animal Clinic, PA and its agents from any liabilities related to complications that may arise due to undetected health issues.
Signature Only If Decline Bloodwork
YesNo
YesNo
YesNo
Any files you would like to upload? Photos, etc.

Cancelof

Anesthesia release Waiver
• To the best of my knowledge, my animal is in good health and is able to undergo the medical procedure. I hereby authorize Hearthstone Animal Clinic to receive, treat, prescribe, transport, care for and house my animal and to perform such anesthetic, medical, surgical and therapeutic procedures as indicated above.

• I the undersigned, certify that I am the owner, or authorized agent for the owner, of the animal described above. I authorize the doctor on duty and assistants to perform listed above and on the attached estimate, including administration of pain relief medications, sedatives, and/or emergency care for the animal. I have been advised as to the nature of the procedures 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 risk of the above and attached authorized procedure(s) and assume full financial responsibility for all charges and services incurred to the described animal.

• I understand that a brief pre-surgical exam (or visual exam of fractious animals) will be performed, and I also understand that the attending veterinarian performing the medical procedure has the right to decline to perform any procedure on any animal for any reason.

• I acknowledge that I will receive the Post-Surgical Home Care Instructions and will provide proper postsurgery monitoring and care for my animal including, but not limited to, the Instructions. (This may include purchasing an e-collar or surgery suit at pet store.)

•I, the undersigned, am the owner or authorized agent of the pet named above and have the authority to execute this consent. I hereby give [Veterinary Clinic Name] and its authorized agents my consent to administer anesthesia to my pet for the purpose of surgical and/or diagnostic procedures.

I understand that while all reasonable precautions will be taken to ensure the safety and well-being of my pet, anesthesia always carries some risk. I further acknowledge that no guarantees or assurances have been made regarding the outcome or safety of the procedure.

Should any emergency situation arise, I authorize Hearthsthstone Animal Clinic to render necessary medical treatment to my pet.
MonthDayYear
Date
Should be Empty:

Surgical Release Form

Procedure and Details

Waiver and Optionals Portion

Anesthesia release Waiver