Surgical and Dental Client Release Form

Date:

Pet's Name:

Pet's Age:

Pet Species:

Feline

Canine

Is your pet:

Male

Female

Male/Neutered

Female/Spayed

Surgery to be performed today:

Has your pet eaten since 10:00 pm last evening?

yes

no

Has your pet had any vaccine reactions in the past?

yes

no

Does your pet have any known allergies to food, medication, or anesthetic agents?

yes

no

If yes, please explain:

Does your pet have seizures?

yes

no

Is your pet on any medications?

yes

no

If yes, please list the medications with the dosage and frequency that you give these medications:

RABIES VACCINATION: If your pet is not current on his/her rabies vaccine, it will be administered today and charged to your account. We may also update any other past due vaccines such as Distemper and Bordetella.

PRE-ANESTHETIC BLOODWORK: Many conditions such as disorders of the kidneys, liver, and blood are only detectable through blood testing. Testing prior to surgery is necessary to be sure the kidneys and liver are able to process the anesthesia. It also ensures the blood can carry oxygen to the organs, that your pet’s immune system can adequately fight infection, and that your pet has adequate platelets for blood clotting. If abnormalities are detected, your pet’s surgery may be delayed or canceled.

INTRAVENOUS CATHETER: For your pet’s safety, all pets undergoing general anesthesia will receive an IV catheter and fluids. An IV catheter and fluids help to maintain blood pressure, replace blood loss, speed recovery and will allow for quick administration of life-saving drugs in the event of an emergency. It will be necessary to shave the hair from a portion of your pet’s leg when placing an IV catheter.

PAIN MEDICATION: All surgical procedures include an injection of pain and anti-inflammatory medications that will last 12-24 hours. Oral pain medications may be sent home for continued comfort.

E-COLLAR: Our doctors recommend that your pet goes home with an e-collar to prevent any licking and/or chewing at the incision site. Would you like us to fit your pet with one prior to going home today?

yes

no

Please initial any of the following procedures you would like us to perform today at an additional cost.

Nail Trim

Anal Gland Expression

Microchip & Registration

Please check one below

I authorize the doctors of Panther Creek Pet Clinic to implement life-saving measures, including CPR for my pet if emergency treatment is needed. I accept full financial responsibility for all charges related to the treatment of my pet.

I DO NOT authorize the doctors of Panther Creek Pet Clinic to implement life-saving measures, including CPR for my pet if emergency treatment is needed.

** Please acknowledge that you received an estimated treatment plan for the surgery and/or dental procedure in the sum indicated below. Furthermore, you agree to pay in full for services performed, including those deemed necessary for medical and surgical complications, or unforeseen circumstances.

Estimated Treatment Plan Total

Please provide us with a phone number where you can be reached today (between 9:00 am - 2:00 pm)
Please indicate your preference.*

Home:
Cell:
Work:

Surgical and Dental Client Release Form

Date:

Pet's Name:

Pet's Age:

Pet Species:

Is your pet:

Surgery to be performed today:

Has your pet eaten since 10:00 pm last evening?

Has your pet had any vaccine reactions in the past?

Does your pet have any known allergies to food, medication, or anesthetic agents?

If yes, please explain:

Does your pet have seizures?

Is your pet on any medications?

If yes, please list the medications with the dosage and frequency that you give these medications:

Additional Procedures:

Please initial any of the following procedures you would like us to perform today at an additional cost.

IN CASE OF EMERGENCY

Please check one below

** Please acknowledge that you received an estimated treatment plan for the surgery and/or dental procedure in the sum indicated below. Furthermore, you agree to pay in full for services performed, including those deemed necessary for medical and surgical complications, or unforeseen circumstances.

Please provide us with a phone number where you can be reached today (between 9:00 am - 2:00 pm)
Please indicate your preference.*

Surgical and Dental Client Release Form

Date:

Pet's Name:

Pet's Age:

Pet Species:

Is your pet:

Surgery to be performed today:

Has your pet eaten since 10:00 pm last evening?

Has your pet had any vaccine reactions in the past?

Does your pet have any known allergies to food, medication, or anesthetic agents?

If yes, please explain:

Does your pet have seizures?

Is your pet on any medications?

If yes, please list the medications with the dosage and frequency that you give these medications:

Additional Procedures:

Please initial any of the following procedures you would like us to perform today at an additional cost.

IN CASE OF EMERGENCY

Please check one below

** Please acknowledge that you received an estimated treatment plan for the surgery and/or dental procedure in the sum indicated below. Furthermore, you agree to pay in full for services performed, including those deemed necessary for medical and surgical complications, or unforeseen circumstances.

Please provide us with a phone number where you can be reached today (between 9:00 am - 2:00 pm) Please indicate your preference.*

Please provide us with a phone number where you can be reached today (between 9:00 am - 2:00 pm)
Please indicate your preference.*