Anesthesia Release Form

PLEASE READ!!

Due to the recent upper respiratory infectious disease affecting canines we are taking extra precautions for dogs scheduled for surgery.

DO NOT let your dog come in contact with other dogs (that are not a part or your family) within 7 days of your scheduled procedure.

If your dog has been in a kennel, grooming, daycare or visited a dog park, or exposed to another day in the same circumstances, within 7 days of your scheduled procedure give us a call to reschedule.

Appointment Date* This field is required.

Are you a new client to Belleview Animal Clinic?* This field is required.

YESNO

How did you hear about us?* This field is required.

Google

Yelp

Other Internet Search

Sign/Location

Pet Supply Store

Other Vet Clinic

Friend/Family

Other

Friend/Family who referred you* This field is required.

Owner Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Confirm Email

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Pet Name* This field is required.

Pet's Name

Species

New or Current Pet

{PetName[2]}'s InformationBreed/Sex/Age/Color/Weight

Breed

Sex

Spayed or Neutered

Age

Color

Weight

Procedure(s)* This field is required.

Dentistry

Spay/Neuter

Ear Surgery

Lump removal

Orthopedic

Eye Surgery

Cystotomy

Exploratory

Xrays

Other

Orthopedic* This field is required.

Left Knee

Right Knee

Left Elbow

Right Elbow

Left Hip

Right Hip

Ear(s)* This field is required.

Left Ear

Right Ear

Eye(s)* This field is required.

Left Ear

Right Ear

Other* This field is required.

Annotate Image* This field is required.

Would you like to microchip {{PetName[2]}

Yes ($50)

Other

Heartworm Testing & Prevention* This field is required.Heartworm Season is beginning in Colorado. Please choose from one of the following options

I would like my pet tested for heartworm AND prescribed prevention

I would like my pet tested for heartworm but I DECLINE prevention

I do NOT want my pet tested for heartworm and I DECLINE prevention

I'm not sure about heartworm testing and prevention. Please provide more information the day of the procedure.

Do you have any records, files or images you would to upload?* This field is required.

YESNO

Upload file(s)* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

pdf, doc, docx, txt, rtf, html, jpg, jpeg, png

Is {PetName[2]} currently on medications?

YESNO

List all Medications {PetName[2]} is currently taking regularly* This field is required.

List all Medications {PetName[2]} will take the morning of procedure

Medications

My pet is allergic to a medication(s)

I am not aware of any medication reactions

List all Medications {PetName[2]} is allergic to

Has {petName[2]} had any previous anesthetic problems?

YESNO

Give details about previous anesthetic problems

0/255

Health issues not treated or diagnosed at Belleview* This field is required.

No known health issues

Diabetes

GI Issues

Thyroidism

Cancers

Seizures

Blood Disorders

Major Surgery

Other

Give details about Other Health Issues* This field is required.

0/255

In the event that your pet should experience cardiac or respiratory arrest during anesthesia, choose the following resuscitative efforts until you can be contacted further and notified of your pet's status?* This field is required.

If we are UNABLE to contact you if we need to perform additional procedures not listed on the estimate we will proceed according to your consent below:* This field is required.

YES, PROCEED with whatever procedures or services you deem necessary in the best interest of my pet

Proceed ONLY IF amount is LESS THAN the amount specified in next field by 15%. Otherwise, I will be responsible for any future costs associated with having to do additional anesthetic procedure to complete desired outcome of initial procedure.

NO, DO NOT PROCEED and recover my pet from anesthesia. I will be responsible for any future costs associated with having to do additional anesthetic procedure to complete desired outcome of initial procedure. Only if cost is more than 10% of the estimate provided.

Proceed only if ADDITIONAL amount of estimate is less than* This field is required.

In whole dollars

Does your pet have an Elizabethan Collar (E-Collar)?* This field is required.

Elizabethan Collar is a plastic or soft collar used to prevent a pet from reaching an incision area

Please bring the E-Collar with {PetName[2]} for the procedure drop-off. If we do not have one post-procedure you may be charged for a new E-Collar

Type a question* This field is required.

Please bring the E-Collar with {PetName[2]} for the procedure drop-off. If we do not have one post-procedure you may be charged for a new E-Collar

Select Method of Payment* This field is required.WE DO NOT ACCEPT CHECKS

No Cash Payments. Method of payment required even if pet is on a wellness package.

Last 4 digits of the card on file

Contact Information* This field is required.

Main Contact Name

Main Contact Phone

Main Phone Type

Additional Contact Information

Second Contact Information* This field is required.

Second Contact Name

Second Contact Phone

Second Phone Type

Which phone would you like us to send the text-to-pay* This field is required.

TEXT TO PAY : {TextToPay}

You will be sent an invoice total to the phone number you provided that receives text messages. Please pay or call before pickup to help expediete discharge and help the front staff with check-in/check-out flow

Agree* This field is required.

I agree to opt-in to receiving text messages from Belleview Animal Clinic for this appointment. I understand I can opt-out again.

Payment in full is required at the time of surgery release, unless prior payment arrangements in writing have been made prior to this estimate. We accept the following forms of payment. Visa, MasterCard, Discover, Cash, or Pre-approved In-House Financing

Agree to terms for ongoing services* This field is required.

I AGREE TO PAY FOR PROFESSIONAL SERVICES, MEDICATIONS & INVENTORY AS THEY ARE RENDERED. I understand every effort will be made to achieve a successful outcome and to provide for all possible safety in hospital care and handling. I hereby authorize this hospital to receive, prescribe for, treat or perform surgery upon the pet(s) listed on this page(s), as deemed necessary when in the care of Belleview Animal Clinic. I agree to pay for the reasonable costs of collection in the event that collection efforts become necessary.

Anesthesia Permission* This field is required.

Cancellation Policy* This field is required.

Day Before Procedure Instructions

Drop-off time is at 7:30. No later than 8:00 am, unless other arrangements have been made.
No food after 10 PM the night before
Leave water available at all times

Owner/Agent* This field is required.

Date/Time

Date

Hour

Minutes

Anesthesia Release Form