Surgical/Anesthetic Release Form Client Name* First Last Email* Patient Name:* First Contact Phone Numbers During Surgery*Procedures/Treatments to be Performed:*Please initial any additional services you would like to have performed at this time to reduce the need for future visits and minimize discomfort for your pet. The cost for these services is not included in the cost of the procedure. Please ask our Staff for prices.Additional ServicesNail trimAnal gland expressionEar clean/flushMicrochip placementDental cleaning & fluoride treatmentTooth extractions if necessaryPain medication to take homeStatement of CommitmentThe staff of Central Veterinary Hospital (CVH) assures you that we will use our best judgment in caring for your pet. This judgment is based on experience, the physical exam of your pet, and any laboratory analysis you authorize. Accept DeclineSurgical ReleaseI, the undersigned, do hereby certify that I am the owner or authorized agent of the animal mentioned above. I give CVH full and complete authority to perform the medical and/or surgical procedure and associated anesthesia stated below as well as any procedures deemed necessary by the doctor that are in the best interest of my pet. I do release CVH from any and all liability for so performing the surgical procedures.Intravenous Fluids, Flea Medications, and Pain MedicationsI understand that my pet will receive intravenous fluid therapy in conjunction with their anesthetic procedure today. I understand that this requires placement of an intravenous catheter, a minor procedure that will require shaving of one or more legs. Although we choose anesthetics we feel to be the safest in each case, IV fluids help improve the safety of certain surgical events. In addition, IV fluids can help speed a pet's recovery from anesthesia and help our pain control medications work more effectively. I understand that if my pet is discovered to be carrying fleas or other external parasites, he or she will be treated appropriately for such at my expense. I understand that pain control medications will be given in hospital and prescribed for post-surgical use at the doctor's discretion.Payment PolicyI agree to pay, in full, for services rendered including those deemed necessary for medical or surgical complications or otherwise unforseen circumstances. I understand that any provided estimate of fees for presently planned procedures is only a best approximation, and the the final bill may be less or greater than this estimated amount. Should I fail to pay for any services provided, I will be responsible for all service charges and collection fees.Pre-Anesthetic BloodworkMany health problems cannot be identified by a physical exam, therefore we do require, at the Veterinarian's discretion that all pets receive a preanesthetic blood screen to help determine the presence of internal illness that may cause complications with anesthesia. This screening does not guarantee the absence of potential complications, but does greatly reduce the risk of complications and helps identify health conditions that may require medical treatment in the future. The cost of the preanesthetic panel and CBC is $70. Please initial the box that you understand the required blood work.Resuscitation StatusI understand that the doctors and staff of CVH will take all reasonable precautions to ensure the safety of my pet but that adverse events, up to and including death, are possible with anesthesia. In the case that my pet goes into cardiac arrest while under the care of CVH, I approve the use of all reasonable measures to resuscitate my pet. These may include, but are not limited to, CPR, injectable medications, and oral/parenteral medications. I understand that the doctors of CVH will determine what measures are reasonable and at what point such measures should be discontinued. I agree to be held responsible for the costs associated with any resuscitation attempt that is made on my pet.Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
