Surgery Release Form Surgery Release Form If your pet's surgery is a spay or neuter, please fill out the spay or neuter form instead. Name(Required) First Last Pet Name(Required) Pet Name Species(Required)DogCatPhone(Required)This number will be contacted to update you on your pet or in the event of an emergency.Secondary PhoneOwner's Date of Birth(Required) MM slash DD slash YYYY This is required by the DEA for us to dispense certain medications.Type of Procedure(Required)Tumor RemovalCherry Eye RepairForeign Body Exploratory SurgeryC-sectionEar Hematoma RepairAbscess SurgeryLaceration RepairOtherIf not listed above, please write the name of your pet's procedure(Required) Terms and Conditions(Required) I agreeI, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above. I do hereby give Dr. Evelyn Tom, Singing Hills Animal Hospital, their agents, servants and/or representatives full and complete authority to perform the anesthesia/surgery or diagnostic procedure named above. I authorize procedures, at their discretion, that are advised and useful to promote/protect the health of the above described pet. I do hereby forever release Dr. Evelyn Tom, relief veterinarians, Singing Hills Animal Hospital, Inc., their agents, servants and/or representatives from any and all liability arising from said surgery or procedure on said animal. In order to better evaluate the ability of your pet to undergo anesthesia, the doctors require a pre-anesthetic blood test for existing infection, kidney, liver, and overall organ functions no more than 30 days prior to surgery. If not already completed, this blood test will be performed today. Specific blood panel will be determined at the doctor's discretion at an additional fee of $127-199.(Required) I understand For the safety of our patients, an intravenous catheter and fluids are required in all anesthetic procedures. This increases safety by keeping blood pressure higher, increase perfusion of vital organs, increase speed of clearance of anesthesia, and aid in life saving protocols.(Required) I understand I understand pain medications will be administered after surgery.(Required) I understand I understand an e-collar is mandatory to keep pets from licking or chewing after surgery. One will be provided at an additional charge.(Required) I understand I certify my pet has not eaten within the last 12 hours.(Required) I understand I understand my pet is fasted for surgery, however, if an anti-nausea medication is needed, there will be an additional fee of $70-200 (dependent on weight of pet).(Required) I understand I understand my pet must be current on vaccinations. If determined by record or examination that my pet is due for vaccinations, I authorize vaccinations to be performed at my expense.(Required) I understand If fleas or other internal/external parasites are found on your pet, we will administer a treatment to them to prevent the spread of parasites to other pets in the hospital. I authorize the treatment of internal or external parasites at my expense.(Required) I understand I understand the hospital is not responsible for any items I may leave, such as: collars, leashes, toys and blankets.(Required) I understand By checking this box and signing below, I certify that I am the rightful owner of the above named pet and agree to the above statements.(Required) I agree Owner's Signature(Required)
