Authorization for Anesthesia and/or Surgery
Client’s Name_________________________________
Pet’s Name___________________________________
Weight__________________________
Surgical Procedure_____________________________________________________________________
Would you like any of the following services performed on your pet?
Pedicure
Yes No
Home Again Microchip
Yes No
Clean Ears
Yes No
(Registration Fee for microchip $17.99)
Fecal
Yes No
Heartworm Test
Yes No
Express Anal Glands
Yes No
Feleuk/FIV/HW Test
Yes No
Apply Frontline/Advantage Yes No
Refill Medications_________________________________________________________________
Does your pet have any of the following medical conditions:
Heart Condition
Diabetes
Bleeding Disorder
Baby Teeth
Vaccine Reaction
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Estrus, Pregnancy or Nursing
Respiratory Condition
Current on Heartworm Prevention
Medication Reaction
Anesthetic Reaction
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
*As with any surgery requiring general anesthesia, certain risks may result in serious complications or even death. To
minimize risks, we will perform pre-anesthetic bloodwork, place an IV catheter, administer fluid therapy and provide heart
monitoring. Please be aware these precautions are required for all anesthetic procedures.
*During the course of a routine anesthetic procedure, unforeseen health conditions mat be noticed that require veterinary
intervention. We will perform any and all life-saving measures needed in case of emergency at the expense of the owner.
*The veterinarian will pull any teeth that are beyond repair and/or pull deciduous (baby) teeth. Additional dental
procedures and pain medicine will be at an additional cost.
*Fleas and/or ticks on patients will be resolved at the expense of the owner.
*pets must be current on all vaccinations and be current on fecal check to stay in our hospital. Fecal check and vaccines
will be administered at and additional charge, if due, unless the veterinarian determines they cannot be given for health
reasons.
I, ___________________________, have read and fully understand this anesthesia release form.
Signature of Owner/Agent______________________________________________Date________________________
Daytime Phone #_____________________________________Alternate Phone #______________________________
Office use:
DHPP__________ Lepto__________ Bord________ Rabies________ HW Test__________
Fecal__________ Physical /Senior Exam__________ FVRCP__________ Feleuk__________ Rabies__________