Surgery Release Form

(Please Fill Out All *Starred Areas of Form Completely)

*PRE-OPERATIVE LABWORK: The doctor HAS recommended pre-operative blood work for my pet due to risks with the use of anesthesia. Please note: There will be an additional charge for this service. Date Administered (if already administered):
I AcceptI Decline

(By signing and dating I am aware that there are increased risks in the absence of this testing.)

*IV FLUIDS: The doctor HAS recommended IV Fluids during the procedure. When pets are sedated they experience decreased blood pressure from the sedation. IV Catheter and Fluids during the procedure are recommended to reduce this risk. IV Fluids help flush the anesthesia from the kidneys (which aids in sedation recovery), help keep the pet hydrated and gives the doctor a direct line to a vein in case of an emergency.
I AcceptI Decline

(By signing and dating I am aware that there are increased risks in the absence of this testing.)

*Pain Medication: Many animals experience post-operative discomfort or pain. We have available analgesics or pain medication that can help alleviate this discomfort. Please note: There will be an additional charge for this service. I AcceptI Decline

Pets must be free of fleas prior to surgical procedure. If there are any signs of flea infestation upon admission of surgery, the clinic will give your pet a flea treatment prior to procedure. By initialing here you understand that you will be responsible for the additional cost related to this service.

I accept responsibility for payment of all charges, regardless of outcome. I understand that any unpaid balance will accrue a monthly finance charge of 5% of the total balance which I will also be responsible for. I also agree that should my account become delinquent and is referred to an attorney for collection, I will be responsible for all costs of collection and attorney’s fees of 33 1/3% of the unpaid balance at the time of the referral

I ELECT TO PROCEED WITH SURGERY AND/OR SEDATION AT THIS TIME.

*We are now offering “Home Again” Micro Chips for pet identification. A small micro-chip is implanted between the shoulder blades through a sterile injector application. Although anesthesia is not required for this procedure, your pet will experience less discomfort if this is done while under anesthesia for other procedures. The cost for this procedure is $71.99, which includes the microchip and first year’s enrollment fee. This micro-chip is recommended for use in puppies, dogs, kittens and cats of all ages. Please check “I Accept” below if you would like us to implant a “Home Again” micro-chip while your pet is under anesthesia today.

I AcceptI Decline

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Which is greater, 6 or 10?