CLIO ANIMAL HOSPITAL
SURGICAL/TREATMENT RELEASE
Date: ______________________
Owner Name: _____________________________________________________
Animal Name: ____________________________________________________________
***Telephone number where you can be reached today: __________________________________________________
Procedures to be performed:
__________________________________________________________________________________________________
Pre-Anesthetic Blood Profile: We recommend a pre-anesthetic blood chemistry panel on all pets under the age of 5 years old
before anesthesia is administered. A pre-anesthetic blood chemistry panel is required for pets over the age of 5 years.
1.PCV – Detects anemia
2.SGPT/ALT – Detects liver damage
3.Total protein – Liver function test
4.BUN – Kidney function test
___Please perform the recommended presurgical blood screening on my pet prior to administering anesthesia.
___I decline the recommended presurgical blood screening on my pet at this time.
___Bloodwork was performed on____________ Type of panel _____________ Results __________________
Pain Medication: In order to provide compassionate high quality medical care for our patients, post-operative pain medication
may be administered to your pet. Please ask us if you have questions or concerns about pain control.
**Please provide SS# _______________________________. This is MANDATORY by the State of Michigan for the
dispensing of any controlled substance. **
Fluoride Treatment: Fluoride has been shown to strengthen tooth enamel, reduce tooth sensitivity and is most beneficial when
applied during the first 18 months of life.
_____ Please apply fluoride to my pet’s teeth today.
_____ I decline fluoride treatment for my pet at this time.
Micro Chipping: Individual numbers are registered in the national database managed by Datamars Recovery Service. The
cost for implantation of this microchip is $52.00 (includes activation and enrollment fee into recovery program).
_____ Please Datamars Microchip my pet while under anesthesia
Alternate Contact ________________________________Phone of Alternate Contact:___________________
_____ I decline micro chipping at this time
Authorization to Resuscitate: Any procedure involving the use of anesthesia carries a serious risk. In the event of possible
complications due to anesthesia:
_____ I give authorization to initiate resuscitation efforts for my pet.
_____ I decline resuscitation efforts for my pet.
Payment Policy: The owner/agent acknowledges, accepts and assumes full and total financial responsibility for any and all
services rendered by the hospital, its staff or employees in the treatment of the above described animal and to pay for such
services when the services are performed or when the animal is picked up from the Hospital. We require a 50% deposit for all
non-routine surgeries and hospital care at the time the pet is admitted. The balance is due at time of discharge. We accept
cash, checks, VISA, and Mastercard.
Authorization to Treat: I fully understand the terms of this agreement and do authorize the hospital staff to perform the aboveindicated services on my pet. I am the owner or authorized agent of the owner of the pet presented for care.
Signature:________________________________________________
Date:_______________________