Surgery & Anesthesia Release Form

Save time at your pet’s surgery appointment. Complete your required surgery and anesthesia release form online before your visit.

Surgery & Anesthesia Release Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet before your visit.
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Owner Name
Address
  • Permission to admit patient and perform procedure(s): I, as owner or owner’s representative, authorize the above procedures to be performed for my pet. If any unforeseen medical needs arise and I am not available, I grant permission for any necessary care to be administered.
  • Pain Control: In order to reduce the anxiety and discomfort to your pet that is associated with surgical procedures, a pain injection is given to all of our surgery patients. These analgesics can improve healing and recovery by reducing the physiologic effects of stress and pain on your pet.
  • Pre-Anesthetic Bloodwork: Your pet is scheduled for a procedure that requires anesthesia. We would like to take this opportunity to explain the use of preanesthetic testing and it’s importance to the health of your pet.

Like you, our greatest concern is the well being of your pet. Before placing your pet under anesthesia, a veterinarian will perform a pre-anesthetic physical to help identify existing medical conditions that could complicate the procedure and compromise the health of your pet. It is important to understand that a pre-anesthetic profile does not guarantee the absence of anesthetic complications. It may, however, greatly reduce the risk of complications as well as identify medical conditions that could require medical treatment in the future.

Because there is always the possibility a physical exam alone will not identify all of your pet’s health problems, we strongly recommend that a preanesthetic profile (a combination of tests) be performed prior to anesthesia. The tests we process are similar to and equally as important as those your own physician would run if you were to undergo anesthesia.

For pets under 3 yrs

The combination of blood tests we recommend for the apparently healthy younger pet is: CBC, BUN, Creatinine, ALK, ALT, Glucose, Total Protein (Kidneys, Liver, Diabetes, Hydration, Protein, Infection, Anemia) $ 72.00

I have been informed of the importance of pre-anesthetic tests to minimize risks associated with the use of anesthesia.

For pets 3 yrs and above

This combination of blood tests is required for the older pet. In addition, this is also required for the more extensive, non-routine surgery regardless of age of the pet: CBC, BUN, Creatinine, ALK, ALT, Glucose, Total Protein (Kidneys, Liver, Diabetes, Hydration, Protein, Infection, Anemia) $72.00

Please Initial

ECG Screening

A pre-anesthetic ECG can be performed to evaluate cardiovascular function prior to anesthetizing your pet. This will be evaluated by a cardiologist and recommendations will be made regarding the anesthetic protocol. $91.84

I have been informed of the importance of pre-anesthetic ECG to minimize risks associated with the use of anesthesia.
Please Initial

Laser Therapy

Laser therapy is a proven, non-surgical, drug-free solution, which increases the body’s natural healing processes. It can help reduce pain and inflammation while accelerating healing. $20

I have read and understand the above information.
E-collars are needed for safe post surgery care. (Cost $11.45 to $28.58).
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