Surgery Release Form

, do hereby certify that, at I am the owner (or duly authorized agent for the owner) of the animal described above, and I do hereby give Hallie Ray Moore, DVM, her agents, servants and/or representatives full and complete authority to perform the surgical procedure described as:
and to perform any other procedure that, at her 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, her agents, or representatives from any and all liability arising from said surgery on said animal. If fleas are found on my pet, I understand he/she will be treated with Capstar. I assume full responsibility for all charges incurred in the care of this animal; these charges will be paid at the time of release and a deposit may be required for surgical treatment. I understand that some risk always exists with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. I understand that subsequent procedures or complications including but not limited to anesthesia, repair of surgical sites, antibiotics, or wound management are not covered by initial surgery cost. My signature on this form indicates that any questions I have regarding the following issues have been answered to my satisfaction:
  • The reasonable medical and/or surgical treatment options for my pet
  • Sufficient details of the procedures to understand what will be performed
  • The most common and serious complications
  • The estimate of the fees for all and any services
  • Pre-operative blood work is mandatory for all pets undergoing anesthesia. This test assists us in evaluating your pet’s health to be certain your pet may process the anesthesia without complications. If not done before today, the cost for preoperative bloodwork is $100.26
  • I would like any mass removed to have a histopathology performed on it for $152.87 (1 site). Each additional site for histopathology is $37.38 each.
  • I would like any remaining baby teeth to be extracted, if possible, during surgery.
  • I would like my pet microchipped during surgery for $60.00
  • Should an unexpected critical situation arise (choose one)
    Accept Terms