Surgery Release Form

E-mail Address:

Pet's Name:

Please read the following and respond:

By indicating I agree and submitting this form, I hereby authorize the Dale City Animal Hospital to perform the above procedures on my pet. I understand that in the event additional procedures are deemed necessary, an attempt will be made to reach me before proceeding, but I understand that the veterinarians are authorized to perform any necessary procedures if they are unable to reach me.

I have read this statement and

I agree I do not agree

with its stipulations.

Please read the following and respond:

By indicating I agree and submitting this form, I acknowledge that I understand that current bordatella (dogs only), distemper, and rabies vaccines and a current fecal test are all required for pets before admission to the hospital. For those pets not current, vaccines and a fecal test will be updated as long as it is deemed safe and advisable by a veterinarian.

I have read this statement and

I agree I do not agree

with its stipulations.

Please read the following and respond:

By indicating I agree and submitting this form, I certify that my pet is free of all external parasites upon signing this release. If parasites, such as ticks or fleas, are found, I understand that my animal will be treated on admission for an additional cost.

I have read this statement and

I agree I do not agree

with its stipulations.

Please read the following and respond:

A pre-anesthetic blood screen will be performed on all pets undergoing anesthesia or sedation. Because we will be using injectable and oral medications, it is important to know whether there are any detectable signs of organ dysfunction. The cost of this procedure is $53.00.

I have read this statement and

I agree I do not agree

with its stipulations.

Please read the following and respond:

A blood pressure check should be done on an animal undergoing an anesthetic procedure. the cost of this check is $20.00.

I have read this statement and

I do I do NOT

want a blood pressure check done.

Please read the following and respond:

To provide for the greatest safety and well-being of all pets undergoing anesthetic procedures, we encourage the use of an indwelling (intravenous) catheter and the use of fluids. Fluids help maintain the animal's blood pressure, protect the kidneys, and prevent deydration. The cost of this procedure is $78.08.

I have read this statement and

I do I do NOT

authorize the placement of an indwelling catheter and the use of fluids.

Please read the following and respond:

My pet will fast for 12 hours prior to surgery: Yes No (We will confirm this on admission.)
My dog is on heartworm preventive: Yes No Not a dog
To the best of my knowledge my dog/cat is is not in heat or pregnant.
(Spaying an animal that is pregnant, obese, or in heat involves additional charges.)

Please read the following and respond:

We believe that keeping your pet as comfortable and pain-free as possible after the surgery will speed healing and recovery. Many animals do not show obvious signs of pain after surgical procedures, so it is up to us to provide them with pain relief both during and after procedures, before they show signs of discomfort. We use injectable medications both pre-and post-operatively. For continued pain relief at home we provide either a continuous release skin patch (strongly recommended for more painful procedures) or tablets. The cost of the tablets runs from $18.00-35.40, and the cost of the patch is $43.20-120.00, depending on the size of your pet.

I prefer the following for my pet's post-operative pain relief: (choose one)

Tablets
Patch
Doctor's Choice

Please read the following and respond:

By indicating I agree and submitting this form, I acknowledge that I have received an estimate for the above procedures and I understand that an effort will be made to contact me if any additional charges arise.

I have read this statement and

I agree I do not agree

with its stipulations.

Please read the following and respond:

A dental cleaning may be performed while your animal is under anesthesia. Please see the receptionist for an estimate.

I have read this statement and

I do I do not

want a dental cleaning performed on my animal.

The Home Again Microchip is the professional way to identify your pet. A tiny microchip that contains a personal one-of-a-kind ID number is placed under the skin. The cost of this procedure is $55.00 plus registration.

I have read this statement and

I do I do NOT

authorize the placement of an Home Again Microchip.

Please read the following and respond:

A tattoo is another way to identify your pet. Your personally selected number is tattooed on the right inner thigh. The cost of this procedure is $43.30 plus registration.

I have read this statement and

I do I do NOT

authorize a tattoo.

My personally selected number (usually a Social Security number) is:

On the surgery date, I can be reached at this phone number: