Surgery Treatment/Anesthesia Release Form

Surgery Treatment/Anesthesia Release Form
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:

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.

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

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