Bardstown Veterinary Clinic
Surgery/Anesthesia Release Form
Client Name:
Case No:
Address:
Pet Name:
Breed:
Age:
Color:
Sex:
Number you can be reached at today:
Your pet is being admitted to our clinic for:
___________________________________________________________________________________
At Bardstown Veterinary Clinic we take all possible precautions to ensure the safety of your pet. We feel certain precautions are
not options. As an example of this, a heart monitor is automatically done for all anesthetic procedures. We strongly recommend
pre-anesthetic blood testing for all our patients. However, in younger, apparently healthy pets, this does remain an option for
you. In pets over 8 years, we require basic testing.
_______Yes, I request a blood test to check the health and status of my pets' liver and kidneys and also to do a complete blood
count prior to anesthesia. This price is $____________________.
_______No, I do not want the pre-anesthetic blood work done at this time.
We now offer microchipping as an option to help recover lost pets. Please consider this option since many times pets can lose
their collars outside and have nothing to identify them as your pet.
_______Yes, I would like my pet to be microchipped while under anesthesia today. This price is $56.99. This price also includes
registration into the Home Again Microchip National Database.
_______No, I do not want my pet microchipped at this time.
Bardstown Veterinary Clinic and its employees have the right to take photographs and/or videos of me and my pet to use
in social media websites. These will be published with or without use of mine or my pets name for any lawful purpose
based on my wishes when the photo is taken. _____Yes ____No
Please Initial Below:
_______ I understand that all precautions are being taken with my pet but that occasionally arise. I authorize the doctor and staff
of Bardstown Veterinary Clinic to pursue any reasonable emergency procedures should they be needed. I will be financially
responsible for this.
_______ I understand that if my pet is found to have fleas or ticks on them that they will be treated with Advantage Multi or
Frontline at a cost to me between $14.00 and $17.80, depending upon the size of product required.
_______ I understand that if my pet is not current on all its vaccinations including Rabies and Feline FVRCP-C, and should my pet
be healthy enough to respond to the vaccine, the vaccine will be given and the fee added to the invoice.
Rabies $9.50
FVRCP-C $23.50
FVRCP-C w/ FeLv $29.50
How would you like us to contact you after surgery?
__Phone:#________________ __Text#______________ __Email Address______________________
The estimated cost for today’s procedure is $_____________________.
_______________________________
(Signature)
_______________________________
(Date)