Owner's Name *

First

Last

Email *

Pet's Name *

1. I authorize the following treatment(s)/surgeries for my pet(s): *

2. 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.

To authorize bloodwork, please choose the age category that best fits your pet: *

IN HOUSE (CBC+12CARD+UA)
COMPLETE WITHIN THE LAST 30-45 DAYS
MICROCHIPPING
I DECLINE BLOOD TESTING (MUST ALSO INITIAL BELOW)

blood use event

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. *

Clear Signature

3. Please list all phone numbers where you can be reached on the DAY OF SURGERY:

Phone *

Location (Home, Cell, Work): *

Alternative Phone number to contact: *

Location (Home, Cell, Work): *

4. 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): *

Perform any additional treatment(s) recommended
Call me first, but if you cannot reach me by telephone, you may proceed with any procedure(s) deemed necessary.
Do nothing else unless you reach me by telephone, text, or email. I understand that you will recover my pet from anesthesia without doing any additional procedures, no matter how minor. I also understand that should I agree to the recommended procedure(s) at a later time, it will be a separate anesthetic and procedure and I will be charged separately.

If you selected for us to proceed with treatment, please list financial limit in the event further treatment is recommended.

CPR Authorization *

In the event your pet experiences an unexpected medical emergency, such as cardiopulmonary arrest while under anethesia, immediate action is critical. Please indicate below where you authorize us to perform Cardiopulmonary Resuscitation (CPR) or if you decline such intervention.

CPR Authorization *

I authorize CPR: I understand there are risks and costs associated with CPR, and I authorize the veterinary team to perform CPR in an attempt to resuscitate my pet in the event of an emergency.
Do NOT perform CPR: I understand that by declining CPR, it is very likely that my pet will not survive in the event of a cardiopulmonary arrest.

5. I accept the conditions outlined in this Surgery Treatment/Anesthesia Release Form: *

Yes

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My submission of this form indicates that any questions I have regarding the surgical procedure and the anesthetic risks have been addressed and I understand and accept them.

Signature *

Clear Signature

Today's Date *

Surgery / Anesthesia Consent Form

Surgery Treatment / Anesthesia Release Form

2. Blood Profile/CBC/Chemistry Panel

3. Please list all phone numbers where you can be reached on the DAY OF SURGERY:

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