Anesthesia/ Surgical Release Form

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Anesthesia/Surgical Release Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Client Name *

First

Last

Patient Name *

Phone number at which owner can be reached today or tomorrow: *

Additional number

Email *

Before Procedure

Would you like to be contacted before your pet goes in for the procedure *

After Procedure

On the day of your pet’s procedure, are there any times when you will NOT be available to pick up your pet? *

Please note - We cannot schedule an exact pick-up time until after the procedure is completed.

After your pet’s procedure is complete, would you like to have a secure link sent to your phone for payment? If so, please indicate Debit/Credit or Care Credit. *

Yes - Credit/Debit card
Yes - Care Credit
No - plan to pay at pick-up

Anesthetic and surgical procedure(s) to be performed: *

I, the undersigned owner or agent of the pet identified above, authorize the staff of Companion Pet Care to perform the above procedure(s). *

I agree

Microchip: There is an additional fee for this procedure *

Yes
No
Already has one

Nail Trim: Would you like a free nail trim for your pet? *

What medications will your pet be given on the morning of their procedure?

Presurgical Pack
Carprofen
Other
None

When was the last time fed?

Any other concerns/allergies/procedures?

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.

I have read and agree

I am over 18 and understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff may or may not have my permission to proceed with life sustaining procedures

I give my permission [yes]
I do not give my permission [no]

While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from the hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree

I certify that I am 18 years of age or older and responsible for the financial and medical decisions for the above mentioned pet.

I agree
I disagree

Signature *

Clear Signature

Date *

Anesthesia/ Surgical Release Form

Anesthesia/Surgical Release Form

Before Procedure

After Procedure

Ready To Visit?

Questions?

Location

Contact Information

Hours