Surgery Release Form

All Pets Must Be Current On Vaccinations

Please don’t give your animal food or water the night before the surgery starting at 8 PM.

Our concern is for the safety, health and comfort of your pet. It is important that we assess the-complete health status of your pet before undergoing anesthesia and surgical procedures. We will perform a physical exam and we strongly recommend a blood profile for all patients. This test is similar to the tests that your own physician would run if you were to undergo anesthesia. This bloqd profile helps alert us to ttie presence of dehydration, anemia, infection, diabetes and/or kidney or liver disease that could complicate the procedure. For patients over 8 years of age a blood profile is required unless already completed in the past 30 days. IV fluids are also required for animals 8 years or old. We also recommend a test to detect blood clotting disorders for major surgeries.

Please check the options below you'd likeI authorize a blood pofile prior to anesthesia for a fee of $64.50I authorize a Clotting Disorder Test for $35.00I have elected to decline both blood tests and understand the potential risksI authorize a pain shot if needed after surgery for a fee of $10.00Home aPain Relief if needed

Please select below if you would like any other services performed while your pet is sedated.Toe Nail Trim $10.00Anal Sacs Expressed $12.00Microchip $43.00Heartworm Test $29.50Other

Pet History

Please provide the following information:

As the owner of the pet described above I hereby give Bonner Springs Animal Care Center, its Doctors and staff consent and authority to provide the above described procedure. I understand the procedure as it has been explained to me. I have been informed that there are certain risks and potential complications and those conditions may arise that require c~anges in the treatment procedure. I authorize the use of the appropriate medical treatment including anesthetics and analgesics before, and after the procedure.

Owner's Signature