Surgery/Dental Release Form

Client: *

Patient: *

Procedure:

Please read carefully and sign:

It is RECOMMENDED for all patients undergoing anesthesia but IS REQUIRED for patients 7 years or older, to receive an IV catheter and fluids to help maintain hydration, blood pressure, and overall safety during anesthesia. The additional cost is $50.

We also STRONGLY recommend a blood profile to check your pet’s health prior to performing the procedure. Test results will also serve as future reference values should your pet become ill.

Please choose an option in each section below:

Pet Health Screen (blood profile):This is a series of tests that check kidney and liver function, blood sugar, and protein, as well as the white and red blood cell count and platelet count. These tests are similar to those that your physician would run if you were undergoing anesthesia. This is an additional cost.

CBC and Chem 17 - $150 This is a comprehensive profile & suggested for animals over 7 years old.Decline

Pain Medication:This is a medication administered to your pet before surgery that lasts 24 hours for pain and is highly recommended with any procedure. This additional cost is $6.00. This is a REQUIREMENT for orthopedic surgeries and declaws.

YesDecline

Vaccinations:Your pet MUST be current on ALL vaccinations to be admitted for surgery. If your pet is not fully vaccinated or not old enough to be fully vaccinated, they will be brought up to date on the day of surgery.

Check all that need updating:

DHLPP:

Bordetella:

Rabies:

FeLV/FVRCP:

Additional services:

Heartworm Test:

Fecal:

Express Anal Sacs:

Check Ears:

Check Skin:

FeLV/FIV Test:

Microchip:

Other:

* If your pet is undergoing a dental procedure and extractions are necessary, there will be an additional charge depending on the difficulty of the extraction.*

* Any pets with fleas will be treated, and there will be a nominal charge.*

Owner Signature: *

Date: *

Primary Contact Number: *

Secondary Contact Number:

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Surgery/Dental Release Form

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Please choose an option in each section below:

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