Anesthesia and Surgery Release ver 5.1
I, ______________________________ am leaving my pet ____________________ for the following
print your pet’s name
please print your name
procedure(s) that will require anesthesia:
1.___________________________________________________________________
2.___________________________________________________________________
3.___________________________________________________________________
Note: If growths are to be removed, please complete the back of this form.
I understand the risks involved with anesthesia and surgery. I understand that my pet could suffer
injury or death due to anesthetic and/or surgical complications.
I do hereby authorize the Briarcliff Animal Clinic to perform surgery and/or to anesthetize my pet, and
declare that I am the legal owner or authorized custodian of this animal. I release the Briarcliff Animal
Clinic, Dr. Peter J. Muller and all his agents or representatives of all legal responsibility for this
animal.
Signature___________________________________
Date_________________
It is very important that we are able to contact you by phone 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 for all patients to identify any underlying
medical problems that may cause complications with your pet’s anesthesia.
A CBC & Chemistry Profile (Glucose, BUN, Cr, ALP, ALT, TP) will be performed at
a cost of $103.00 unless it has 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.
Pricing is based on patient’s weight.
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 $85.00.
NO WATER AFTER 8AM THE DAY OF SURGERY
NO FOOD AFTER 12AM 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.