Surgery Release Form

Cave Spring Animal Hospital

19 Alabama Street Cave Spring, Georgia 30124 Telephone: 706-381-2500
Surgery Release Form
Client Name:*
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Telephone:*
Please enter a valid phone number.
E-Mail Address:*
example@example.com
Pet Name:*
Breed:*
Sex/Altered?*
Color:*
Age:*
Weight:*
Pre-Surgical exams are required for ALL pets that have not been examined within 6 months. Please answer the following questions regarding your pet's history:
Is your dog on heartworm prevention?*

YesNo
Has your pet been checked for internal parasites in the last six months?*

YesNo
Any vomiting, coughing or diarrhea noted?*

YesNo
Has your pet eaten this morning?*

YesNo
Has your pet been ill or injured in the past 30 days?*

YesNo
Is your pet allergic to any medications?*

YesNo
What medications is your pet allergic to?
We recommend a blood panel be run before the surgery to help detect any internal problems that may not be evident upon a physical examination. This process includes drawing a single blood sample. The cost of the recommended blood panel is $ . .
Pain medication, consisting of 1 injection prior to surgery as well as take home tablets or liquid is required for all surgical proceedures. The cost of the pain medication is $ . .
Do you want the recommended blood panel?*

Yes, I want the recommended blood panel.No, I do not want the recommended blood panel.
Would you like to have any additional procedure(s) done while your pet is under anesthesia? If so what?
Telephone number where the owner can be reached*
Please enter a valid phone number.
Surgery to be performed*
I am the owner or agent for the above described animal and have the authority to execute this consent and authorization of the above named surgery(s).
I understand that during the performance of the procedure(s), unforseen conditions may be revealed that necessitate an extension of the foregoing procedure(s), or even different procedure(s), than those set forth previously. I hereby consent and authorize the performance of such procedure(s) as necessary and desirable in the
exercise of the veterinarian's professional judgement. I have been advised of the nature of the procedure(s), as well as the risks involved, and also realize that results cannot be guaranteed.
I additionally authorize the use of appropriate anesthesia, pathologist examination of excised tissue as deemed appropriate by the veterinarian, and the administration of other rmedications, and understand that hospital staff will be utilized as deemed necessary by the veterinarian. I have read and understand this authorization and
consent.
Date*

MonthDayYear
Date
Signature of Owner or Agent*

Clear
Should be Empty:

Cave Spring Animal Hospital

Surgery Release Form

Pre-Surgical exams are required for ALL pets that have not been examined within 6 months. Please answer the following questions regarding your pet's history: