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Surgical Release Form
Client’s name
(Required)
First
Last
Pet’s Name
(Required)
Date of procedure
(Required)
MM slash DD slash YYYY
Procedure to be performed
MM slash DD slash YYYY
Has your pet ever had a seizure?
(Required)
Yes
No
Has your pet eaten in the last 12 hours?
(Required)
Yes
No
Has your pet had water in the last 12 hours
(Required)
Yes
No
Does your pet have any known allergies?
(Required)
Yes
No
If yes, what?
(Required)
Is your pet on any current medications?
(Required)
Yes
No
If yes, what?
(Required)
Did you give your pet the pre-visit medication?
(Required)
Yes
No
At what time?
(Required)
Is your pet experiencing any problems you would like a doctor to examine?
(Required)
Additional Services Requested (please check all that apply)
(Required)
Microchip: While your pet is under anesthesia, a permanent I.D. chip can be painlessly implanted under the skin. Cost: $88.00 (includes registration fee)
Fecal: To prevent the spread of parasites to other pets and family members, we recommend testing a yearly fecal sample: Cost: $43.50
Heartworm Test: If your pet has not been tested in the last 6 months and not currently on prevention, we recommend testing today. Cost: $53.00
Nail Trim: We can trim your pet’s nails while they are under anesthesia today.
Vaccinations: We require all pets to be up to date on vaccines (Rabies, distemper and bordetella for dogs and rabies and distemper for cats)
OraVet Sealant Treatment- Cost: $76.09
CPR Status:
(Required)
Perform CPR
Do Not Resuscitate
I agree
(Required)
I agree to I authorize the doctor(s) at Lake City Animal Clinic to perform the above anesthetic and surgical procedure(s) described above. I understand that some risks always exist with anesthesia and/or surgery ranging from post-op nausea to death and I am encouraged to discuss any concerns that I have. While I understand that all procedures will be performed to the best of the abilities of the staff at Lake City Animal Clinic, I understand there is no guarantee regarding the results that may be achieved. I also understand that all charges will be paid in full at the time of releasethe privacy policy.
(Required)
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Contact Number
(Required)
Contact Number
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