Surgery Treatment/Anesthesia Release Form
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Pet's Name:
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1. I authorize the following treatment(s)/surgeries for my pet(s):
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2. Laser Surgery Option
Laser surgery has many benefits including less post operative pain, less swelling and inflammation, less bleeding and faster healing.
Laser surgery prices Level I: $65 Level II: $85, Level III: $115, Level IV: $175
Please check one of the following:
Yes, I want laser surgery for my pet and I understand the additional cost
No, I decline laser surgery for my pet.
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3. Blood Profile/CBC/Chemistry Panel
The use of anesthesia poses a potential health risk to your pet. To decrease the risks associated with anesthesia, a current pre-anesthetic blood profile (CBC/Chemistry Panel) is highly recommended. A blood profile can rule out any pre-existing conditions that may not be evident physically, but could lead to serious complications. This profile includes tests that check for anemia, infection, diabetes, kidney/liver failure, and other potential underlying problems.
Please note that the
fees for this blood work are in addition
to the cost of the scheduled procedure. Also, immature pets, aged pets, and sick/debilitated pets are in a higher risk group and may need more extensive blood work than what is offered on this release form. If your pet is in this higher risk group, please discuss blood work fees with the Doctor.
Please choose the age category that best fits your pet:
Routine (Under 2 yrs.) $45.00
Intermediate (2-6 yrs) $70.00
Comprehensive (7+ yrs) $115.00
IN HOUSE (< 2 yrs) $95.00
IN HOUSE (2-6 yrs) $110.00
IN HOUSE (7+ yrs) $135.00
MICROCHIPPING $40.00
I DECLINE BLOOD TESTING (MUST ALSO INITIAL BELOW)
TO DECLINE
the recommended blood work please initial below the following statement:
I understand that there is a potential risk of death associated with the use of anesthesia. I DECLINE the recommended blood work and request that you proceed with the authorized procedure.
INITIALS:
4. Please list all phone numbers where you can be reached on the
DAY OF SURGERY:
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Number:
Location (Home, Cell, Work):
Number:
Location (Home, Cell, Work):
Number:
Location (Home, Cell, Work):
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5. In the event it is determined that your pet(s) need additional treatment and we are unable to reach you at the phone numbers provided above, please indicate the course of action you would like us to take: (INITIAL ONLY
ONE
SELECTION)
I trust your decision to perform any additional treatment and/or surgery needed for my pet’s health.
Please perform only the scheduled procedure(s) authorized above.
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6. Your Email Address:
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7. Your Name:
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8. I accept the conditions outlined in this Surgery Treatment/Anesthesia Release Form.
Yes
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Indicates Response Required
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