Download surgery release form - Seminole Trail Animal Hospital

www.seminoletrail.com
407-366-4486
Fax 407-366-5969
Seminole Trail Animal Hospital
Owner:
Street:
City:
Phone:
Email:
[email protected]
SURGERY RELEASE FORM
Patient:
Sex:
Age:
Color:
Breed:
I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the
animal described above, that I do hereby give Dr. Paul Williams, his agents, servants, and/or
representatives full and complete authority to perform the surgical procedure described as:
_________________________________________________________________________________
and to perform any other procedure that, at his discretion, may be useful to promote the health of the
above described pet, and I do hereby and by the presents forever release the said doctor, his agents,
servants, or representatives from any and all liability arising from said surgery on said animal.
We will perform a full physical examination on your pet before administering the anesthesia. We also
require a pre-op blood profile and EKG to be performed for the purpose of insuring your pet to be in a low
risk category during anesthesia. By performing this important pre-op blood profile, we will be able to rule
out most pre-existing internal problems that may not be evident physically, but could lead to serious
complications. There is an additional fee of $91.10 to run these important procedures.
The administration of post-operative pain medications is also required. Certain surgeries require postoperative pain medications due to the nature of the procedure, but it is even beneficial with elective
surgeries (spaying and neutering). Not only does post-operative pain add unnecessary discomfort to your
pet but also unrelieved pain can considerably slow the healing process. This is included in the price of the
surgery.
While your pet is under anesthesia, we can microchip him/her for permanent identification. Every year
more than 20 million dogs and cats are put to sleep because humane shelters cannot identify the pet or its
owner. A microchip is an unmistakable sign that the pet is not only loved, but very much wanted. The
cost during the surgical procedure is $61.00. This includes the HomeAgain® program enrollment.
Please microchip my pet _______
Please do not microchip my pet _______
Would you prefer a text message or phone call after surgery is finished? Text
Phone call
Best number for text message (if requested):______________________________________
Phone Numbers where you can be reached today (necessary in case doctor has any questions):
__________________________________________________________________________
Signed ____________________________________________ Date ___________________