Surgery Release Form
Today's Date
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Month
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Day
Year
Date
Your Name
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First Name
Last Name
Where would you like us to call/text you after surgery?
Please enter a valid phone number.
Format: (000) 000-0000.
Pet's Name
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Procedure Your Pet is Here For
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Flea control will be given to your pet if fleas are found when your pet is presented for surgery. We use the Capstar pill for dogs and cats.
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I understand and agree to pay for this treatment.
Would you like any other procedure with your pet's visit today? (additional fees apply)
Nail Trim
Ear Cleaning
Microchipping- recommended for all patients
Express Anal Glands
Other
Bloodwork
Many conditions, including disorders to the liver, kidneys, and blood, are not detected unless proper blood testing is performed. Such tests are especially important before any anesthetic procedure. Our laboratory is equipped to perform these tests with immediate results available for review by our veterinarians.
I request the following bloodwork be performed for my pet. (additional fees apply)
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CBC- recommended for patients less than 1yr old.
CBC and Chemistry- recommended for patients over 1yr old, required for patients 3+yrs old.
I decline bloodwork at this time (only for patients less than 3yrs old).
Feline patients should have a Feline Leukemia/Aids test prior to surgery. These diseases dramatically increase a pet's anesthesia risk and affect the way we care for your cat before, during and after the procedure. (additional fees apply)
Please test my cat for FELV/FIV.
I decline testing at this time.
IV Catheter allows for immediate administration of medication, if needed at any time during the procedure. (additional fees apply)
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I want my pet to have a catheter.
I decline a catheter at this time (only for pets less than 8yrs old).
Pain Relief
Most patients will feel discomfort after their procedure. We will give a pain injection prior to surgery that will last 12-24 hours after the procedure. Would you like additional oral pain medication to give at home? (additional fees apply)
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Yes, I would like a prescription.
I decline additional pain medication at this time.
Dental Cleaning
Every effort will be made to preserve as many teeth as possible, however, there are many instances where diseased teeth are identified prior to or during the actual dental procedure. It is the policy of American Heritage Animal Hospital, based on the doctor’s professional judgment, to extract any dead, loose, or severely damaged teeth at the time of the dental cleaning. Dental extractions can range in pricing based on the number of teeth extracted and the difficulty of the extractions.
I agree to have teeth extracted based on the doctor's discretion and to pay any additional cost related to extractions and pain medication. (additional fees apply)
Emergency Information
EMERGENCY Phone Number
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Please enter a number where you can be reached during your pet's procedure.
Format: (000) 000-0000.
In the extremely rare and unforeseen event that your pet should undergo cardiopulmonary arrest during anesthesia or during recovery from anesthesia please initial your preferred treatment. (additional fees apply)
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Perform CPR- including injections, fluid therapy, oxygen, chest compressions, etc.
DO NOT perform CPR or any other life saving measures on my pet.
Client Consent
I, the undersigned owner or agent of the owner of the pet identified above understand that unforeseen conditions may be revealed that necessitate an extension or different procedure(s) and/ or operation(s) than those set forth above. I am acknowledging that I understand that there are risks involved with any anesthetic episode and accept the risk for my pet without liability to American Heritage Animal Hospital, its doctors or its staff members. I recognize that the doctors/staff will take all necessary precautions to minimize these risks as much as possible. All pets are closely monitored throughout the entire procedure and anesthetic episode, including during recovery. Your pet’s mucous membrane color, heart rate and rhythm, respirations, and oxygen level are continuously checked by our staff and anesthetic monitoring equipment.
I certify that I have read this document in its entirety and understand it. I hereby consent to and authorize the doctor at American Heritage Animal Hospital to perform the above procedures and I fully understand the risks involved. I realize that results cannot be guaranteed and that my financial obligation remains regardless of the outcome. I also understand that no staff will be attending to my pet overnight (pets needing close monitoring may be referred to a 24-hour hospital). I assume FULL financial responsibility for this animal and any/all treatments that may be required. I am aware that payment in full is due at the time my pet is released from the hospital. YOU MUST BE 18 YRS OR OLDER TO SIGN THE CONSENT FORM.
Client's Signature
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