Surgical Release Form Owner*Patient*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of BirthBreedPhone*Email* SexSurgical procedure(s)I Hereby authorize and direct the veterinarians of the clinic to perform the procedure and additional diagnostic and/treatment procedures as deemed advisable for the Patient. The nature of the procedure has been explained to me and no guarantee has been made as to the results or cure. I understand that the risk of death can occur during any anesthetic and/or surgical procedure. I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Any estimates or charges for the planned procedures are only approximations, and the final bill may be greater or less than these amounts. All services must be paid for when the Patient is released. Some procedures require a deposit to be made before surgery.We recommend that pre-anesthetic blood test be performed prior to administration of anesthesia in furbabies less than 7 years of age and required for furbabies 7 years and older. These tests can help us detect anemia, dehydration, diabetes, kidney disease and liver disease. All these conditions can contribute to complications in anesthesia and surgery. The cost of the blood tests range from $71 to $130 depending on your furbaby's age.*AcceptDeclinePlease have the doctor callWe recommend intravenous fluids during the surgery to maintain blood pressure and ensure post-surgery comfort in furbabies less than 7 years of age and required for furbabies 7 years and older. The cost of intravenous fluids is $50-$60*AcceptDeclinePlease have the doctor callOur furbabies do not show pain as we do. They do not complain as loudly as we do and they accept the levels of pain that we could not imagine. It has been shown that humans recover better and faster if they are pain free. It is the same for our furbabies. We advise a post-operative pain injection and pain medications to be sent home. The cost of pain medication is $50 to $85.*AcceptDeclinePlease have the doctor callI would like the Patient to have a microchip while under anesthesia. The cost of microchip with registration is $56.34*AcceptDeclinePlease have the doctor callI authorize the doctors and staff to perform any life saving procedures deemed necessary in the event of an emergency.*AcceptDeclinePlease have the doctor callIf we do not have proof of a current Rabies vaccine, one will be given and billed for today if your furbaby is over 3 m.Would you like to have laser therapy performed post operatively to speed healing and reduce pain and inflammation? The cost is $21.*YesNoAppetite, Attitude has been normal?*YesNoTime of last meal : HH MM AM PM Time of last water : HH MM AM PM If no then describe belowAny coughing, sneezing, vomitting or diarrhea*YesNoIf yes, then describe belowList all medications, prescription and/or over the counter, your furbaby is or has received within the last month.Would you like to opt in to texting and receive a photo of your furbaby? Data charges may apply.YesNoIs your canine companion currently on heartworm prevention, if so, if possible list the name and the last date a dose was givenIf an intact female, when was the last heat cycle?If an intact female, do you believe she could be pregnant?*If your furbaby is pregnant then minimum of a CBC and IV fluids will be performed.Any previous medical illness?*YesNoIf yes, please describeAny history of seizures?YesNoIf yes, please describe fluencyIf your canine companion is not currently on heartworm prevention or has not had a recent negative test result, then a heartworm test is A negative heartworm test prior to amnesia is required within the last year if over 7 months of age if we do not have proof of having been on heartworm prevention. If fleas are present on furbaby, I will be charged for a Capstar. If ticks are present I will be charged for Simparica or Seresto Flea & Tick collar.An E-Collar or Cone is highly recommended for all surgical patients, if boarding post-operatively one will be placed upon your furbaby and is required. Exceptions made by doctor's discretion only. Would you like to have an e-collar today to keep your furbaby from licking or chewing at the incision site?YesNoOwner's SignaturePlease enter full namePhone number(s) where you can be reached You may enter up to 3 phone numbers.
