Anesthesia and Surgery Release 8.1
I, ______________________________ am leaving my pet ____________________ for the following
please print your name
print your pet’s name
procedure(s) that will require anesthesia:
1.___________________________________________________________________
2.___________________________________________________________________
3.___________________________________________________________________
It is very important that we are able to contact you while your pet is anesthetized.
On the day of the procedure, I may be reached at (____) _____ - ________ or
(____) _____ - ________
Pre-Anesthetic Bloodwork
Briarcliff Animal Clinic requires pre-anesthetic bloodwork to identify any underlying medical
problems that may cause complications with your pet’s anesthesia.
[ ] CBC & Chemistry Profile (Glucose, BUN, Cr, ALP, ALT, TP) will be performed at a
cost of $121.75 (L-Prep Profile II/CBC).
[ ] CBC & Chemistries have been completed within 90 days of the procedure and are
available for the veterinarian’s interpretation.
Pain Management
It is the ethical standard of this hospital to provide pain management to every pet before, during and
after surgery. An injection will be administered to your pet prior to surgery and during the procedure to
minimize your pet’s discomfort. We may also provide oral pain medications for you to give at home.
IV Catheter and Fluids are required for all surgeries.
Microchips
Briarcliff recommends ‘microchipping’ your pet as a reliable form of permanent identification. Please
indicate below if you would like to have a chip placed in your pet while under anesthesia.
[ ] I do [ ] I do not authorize the placement of a microchip during surgery at an additional cost of
$82.50.
Dentistry
Routine dental cleanings are imperative to maintain your pet’s overall health. Severe dental disease
can cause oral infections as well as heart and kidney problems. This procedure can usually be
performed while your pet is anesthetized for surgery for an additional cost, depending on the condition
of the teeth and gums. If you would like us to perform a dentistry for your pet, please
complete a separate Dentistry release.
NO WATER AFTER 8AM THE DAY OF SURGERY
NO FOOD AFTER 8PM THE NIGHT BEFORE SURGERY
(Please TURN OVER)
Removal of Growths
If any growths, lumps, or tumors are to be removed, please mark their location(s) on the diagram
below.
Also, please mark the growth(s) on your pet using fingernail polish or permanent marker.
* Infrequently, it is necessary to enlarge the abdominal incision due to excessive abdominal fat
deposits blocking visualization and/or access to vital structures. Laparoscopic sterilization prior to the
first heat cycle or in lean patients may minimize the risk of having to enlarge the surgical incision.
I understand that during and/or after procedure(s) listed on this release are performed, unforeseen
conditions may be revealed that require an extension or variance in the procedure(s). I authorize
Briarcliff Animal Clinic to use reasonable care and judgment in modifying my pet’s procedure(s) as
medically indicated. The risks involved with surgery and anesthesia have been explained to me and I
understand results are not guaranteed. I am aware that unforeseen events or complications resulting
from anesthesia and/or surgery (including but not limited to: vomiting, diarrhea, lethargy, pain,
infection, injury or death) may occur, and I will be responsible for all fees associated with the
treatment of these complications as well as the initial procedure.
Signature___________________________________
Date_________________