Highland Lakes Veterinary Clinic
Surgical/Anesthesia Release Form
Owner: ________________________________ Pet’s Name: ____________________________
Address: ____________________________ Today’s Phone #_________________________
As the Owner or Agent of the Owner of the above animal, I hereby give my consent to Highland Lakes Veterinary
Clinic to perform the following procedures:________________________________________________________.
I understand that during the performance of this procedure, unforeseen conditions may be revealed that necessitate
variance in the procedure(s) set forth above. I expect Highland Lakes Veterinary Clinic to use reasonable care and
judgment in performing the procedure(s). The nature of the procedure(s) and risks involved have been explained
to me, and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the
procedure(s)will not relieve me from my obligation to all reasonable costs incurred regarding this animal.
ALL ANIMALS ADMITTED MUST BE CURRENT ON THEIR VACCINATIONS AND MUST BE FREE OF
EXTERNAL PARASITES. ANY ANIMAL FOUND TO HAVE FLEAS OR TICKS WILL BE TREATED AT
THE OWNER’S EXPENSE.
LABORATORY TEST WAIVER
If your pet is to be anesthetized, advances in anesthesia and surgery have made routine procedures relatively safe with
a low rate of complications. Nevertheless, occasional problems can arise due to pre-existing conditions not evident
during routine pre-anesthetic examinations. In an attempt to avoid these problems and insure the best possible care of your
pet please read the following options.
 Pre-Operative Blood Screen Anesthetics are metabolized and eliminated through the body’s organs, primarily
the kidneys and liver. A pre-operative blood screen allows for the use of the correct and safest anesthesia for each
individual pet. For pets over 7 years of age a urinalysis is run to assess renal function and screen for disease.
 Intravenous Catheter A catheter placed prior to anesthesia allows the administration of I.V. fluids to maintain
hydration and kidney function during anesthesia. It also allows faster administration of emergency medicines
should the need arise. Especially recommended for all pets over 7 years of age.
 Surgical Laser Minimizes pain and bleeding and may improve healing.
 EKG Pre Surgical Screen An electrocardiogram checks for cardiac abnormalities.
 T4 - Thyroid Testing Canine – Low thyroid function in older dogs is often related to neurologic problems.
Feline – Increased thyroid hormone in older cats can lead to high blood pressure and subsequent cardiac, eye and
other organ disease.
Please initial below to indicate your choice for today’s procedure on your pet.
These fees are IN ADDITION TO the surgery fee.
Level 1: Pre-Anesthetic Bloodwork + IV Catheter+Laser+EKG
Level 2: Pre-Anesthetic Bloodwork + IV Catheter+Laser
Level 3: Pre-Anesthetic Bloodwork + IV Catheter
Level 4: Pre-Anesthetic Bloodwork
Pets Under 7 yrs
____$257.00
____$204.00
____$119.00
____$74.00
Pets 7-9 yrs
____$312.00
____$259.00
____$174.00
____$129.00
With T4
Pets 10yrs & over
____$372.00
____$319.00
____$234.00
____$189.00
*Laser can also be added to all levels for $85.00; _____ EKG for $53.00; _____ IV Catheter $45.00; _____
______ I decline all the options listed above and understand the increased risk to my pet.
Other services available today while your pet is under anesthesia:
___Microchip-Pet Identification - $38.00
___Extract retained baby teeth - $35.00
___Express Anal glands - $19.00
___Dock tail - $175.00
___Nail trim - $15.00
___Bath/Dip - $$ - varies
___Clean & Flush ears - $29.00
___Surgical nail trim - $35.00
_________________________________________________
_______________________________________
Signature of Owner/Agent
Date
_________________________________________________
Witness
Highland Lakes Veterinary Clinic
Dental/Anesthesia Release Form
Owner: _____________________________ Pet’s Name: ____________________________
Address: ____________________________ Today’s Phone #_________________________
As the Owner or Agent of the Owner of the above animal, I hereby give my consent to Highland Lakes Veterinary Clinic to
perform the following procedures:______________________________________________________________________.
I understand that during the performance of this procedure, unforeseen conditions may be revealed that necessitate
variance in the procedure(s) set forth above. I expect Highland Lakes Veterinary Clinic to use reasonable care and
judgment in performing the procedure(s). The nature of the procedure(s) and risks involved have been explained
to me, and I realize results cannot be guaranteed. I am also aware that unforeseen events resulting from the
procedure(s)will not relieve me from my obligation to all reasonable costs incurred regarding this animal.
ALL ANIMALS ADMITTED MUST BE CURRENT ON THEIR VACCINATIONS AND MUST BE FREE OF
EXTERNAL PARASITES. ANY ANIMAL FOUND TO HAVE FLEAS OR TICKS WILL BE TREATED AT
THE OWNER’S EXPENSE.
LABORATORY TEST WAIVER
If your pet is to be anesthetized, advances in anesthesia and surgery have made routine procedures relatively safe with
a low rate of complications. Nevertheless, occasional problems can arise due to pre-existing conditions not evident
during routine pre-anesthetic examinations. In an attempt to avoid these problems and insure the best possible care of your
pet, please read the following options.
 Pre-Operative Blood Screen Anesthetics are metabolized and eliminated through the body’s organs, primarily
the kidneys and liver. A pre-operative blood screen allows for the use of the correct and safest anesthesia for each
individual pet. For pets over 7 years of age a urinalysis is run to assess renal function and screen for disease.
 Intravenous Catheter A catheter placed prior to anesthesia allows the administration of I.V. fluids to maintain
hydration and kidney function during anesthesia. It also allows faster administration of emergency medicines
should the need arise. Especially recommended for all pets over 7 years of age.
 EKG Pre-Surgical Screen An electrocardiogram checks for cardiac abnormalities.
 T4 Thyroid Testing Canine – Low thyroid function in older dogs is often related to neurologic problems.
Feline – Increased thyroid hormone in older cats can lead to high blood pressure & subsequent cardiac, eye and
other organ disease.
Please initial below to indicate your choice for today’s procedure on your pet.
These fees are IN ADDITION TO the dental fee.
Level 1: Pre-Anesthetic Bloodwork+ IV Catheter + EKG
Level 2: Pre-Anesthetic Bloodwork + IV Catheter
Level 3: Pre-Anesthetic Bloodwork
Pets Under 7 yrs
_____ $172.00
_____ $119.00
_____ $74.00
Pets 7-9yrs
_____$227.00
_____ $174.00
_____ $129.00
With T4
Pets 10 yrs & OVER
____$287.00
____ $234.00
____ $189.00
*EKG Screen can be added to all levels for an additional $53.00; ______ IV Catheter $45.00; ______
All dentals with extractions will be sent home with Pain Medication and Antibiotics.
Pain Medication: Varies by weight and circumstances – Canine $25.00-$35.00 & Feline - $36.00
Antibiotics: Varies by weight and circumstances - $20.00 – $40.00
______ I decline all the options listed above and understand the increased risk to my pet.
Other services available today while your pet is under anesthesia:
___Microchip-Pet Identification - $38.00
___ Extract retained baby teeth - $35.00
___Clean & Flush ears - $29.00 ___Express Anal Glands - $19.00 ___Nail trim - $15.00
___Surgical nail trim - $35.00
___Bath/Dip - $$ - varies
___Dock Tail - $175.00
_________________________________________________
_______________________________________
Signature of Owner/Agent
Date
_________________________________________________
Witness