Authorization for Anesthesia - Animal Medical Center of Greeneville

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ANESTHESIA/SURGERY RELEASE FORM
Client Name______________________ Phone Number(s)_____________________________________
Pet’s Name______________________ e-mail address_________________________ Date__________
Breed__________________________ Birthdate_____________________ Sex____________________
Anesthetic/Surgery release for surgical procedures(s) to be performed: _________________________________
I, the undersigned owner or agent of the owner, of the pet identified above, certifies that I am/am not eighteen
(18) years of age or over and authorize the veterinarian(s) at Animal Medical Center of Greeneville to perform the
above procedure(s). I understand that some risks always exist with anesthesia, sedation and/or surgery. I have
been encouraged to discuss any concerns I have about those risks with the attending veterinarian before the
procedure(s) is/are initiated. My signature on this form indicates that any questions I have regarding the
procedures have been answered to my satisfaction.
While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I
understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to
pay a deposit of 50% of the estimated fees, understanding that this is an estimate, and I will provide the balance of
the payment via cash, credit card, or check at the time my pet is discharged from the hospital. Should
unexpected life-saving emergency care be required and the hospital staff is unable to reach me, the staff has/does
not have (circle one) my permission to provide such treatment and I agree to pay for such services.
I have read and fully understand the terms and conditions set forth above.
_____________________________________________________
Signature of Owner or Agent
____________________________________
Date
____________________________________________________
Signature of Parent or Legal Guardian
(if owner/agent is less than 18 years of age
____________________________________
Date
Phone number(s) at which owner can be reached today and/or tomorrow
Pre-Anesthetic blood work is recommended by Animal Medical Center of Greeneville.
Owner accepts or declines (circle one) pre-anesthetic blood work for________________________.
Pet’s Name
Pain Management is recommended by Animal Medical Center of Greeneville.
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