Surgery Release Form All Pets Must Be Current On VaccinationsPlease don't give your animal food or water the night before the surgery starting at 8 PM.Your Name First Last PhonePlease leave the best phone number we can reach you at today.Email Pet's NameDate 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. We also recommend a test to detect blood clotting disorders for major surgeries.Please check the options below you'd like I authorize a blood pofile prior to anesthesia for a fee of $57.50 I authorize a Clotting Disorder Test for $35.00 I have elected to decline both blood tests and understand the potential risks I authorize a pain shot if needed after surgery for a fee of $10.00 Home aPain Relief if neededPlease select below if you would like any other services performed while your pet is sedated. Toe Nail Trim $10.00 Anal Sacs Expressed $12.00 Microchip $43.00 Heartworm Test $29.50 OtherPlease describePet HistoryPlease provide the follbwing information:Medications currently takingWhen did your pet last eat?Has your pet been feeling/ acting normal this past week?Eating Well?Has there been any recent vomiting/ diarrhea/ coughing?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 SignatureTyping your name above acts as your digital signature.PhoneThis field is for validation purposes and should be left unchanged.
