Town & Country Anesthesia Release Form
Pet Name
First Name
Last Name
Account Number
I Authorize the performance of other procedure(s) or operation(s) necessary and desired in the exercising of the veterinarian’s professional judgment. I understand that I assume financial responsibility for all services rendered, and that payment in full is due when my pet is discharged. I understand and agree that all anesthesia and surgery involves a certain amount of risk to pets. I further understand that results cannot be guaranteed and I will not hold Town & Country Veterinary Hospital or their associates personally liable. If any unforeseen medical or surgical needs arise, I hereby consent to cover the cost of any medications and supplies used in providing necessary care for my pet.
Owner Type Full Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
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Month
-
Day
Year
Date
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