Surgery Release Form - Oak Forest Veterinary Hospital

Client First and Last Name

Email

Contact Number

Street Address

Street Address Line 2

City

State

Zip

Patient Name

Breed

Sex

Age

Color

Markings

I do hereby certify that, 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:

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.

Yes
No

I would like any remaining baby teeth to be extracted, if possible, during surgery.

Yes
No

I would like my pet microchipped during surgery for $60.00

Yes
No

Should an unexpected critical situation arise (choose one)

I authorize and accept financial responsibility for the veterinarian (s) and staff to perform lifesaving procedures.
I choose that the veterinarian(s) and staff DO NOT resuscitate my pet

Accept Terms

I accept that you have read and understand all the above information.

Name

Signature Date