Surgery Treatment & Anesthesia Release Form

Save time at your pet’s surgery appointment! Complete your required forms online before your visit.

Surgery Treatment & Anesthesia Release Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Client Name *

Client Phone Number *

Email *

Pet Name *

Anesthetic and surgical procedure to be performed: *

I, the undersigned owner or owner’s agent, of the pet identified above, certifies that I am over 18 years of age and hereby authorize the veterinary at Westmoreland Veterinary Clinic to perform the above anesthetic and surgical procedure(s) for my pet. 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 procedures is / are initiated. While I accept that all procedures will be done to the best of the abilities of the staff at Westmoreland Veterinary Clinic, I understand that no guarantee or warranty has been made regarding the results that may be achieved. *

I have read and agree to the above statement

I agree to pay a deposit of %

of the estimated fees and assume financial responsibility for the balance of the services on a cash, credit card or check basis at the time my pet is discharged from the hospital.

Pre-operative Laboratory Testing

For the protection of our patients we recommend a pre-operative blood screen at a cost of $

This allows us to make sure that your pet’s liver and kidneys are working adequately to cope with anesthesia and to ensure they are not dehydrated or diabetic at the time of surgery.

Pets below 7 years – testing is recommended. Pets above 7 years – testing is mandatory.

Pre-operative blood work agreement *

I agree to the above pre-operative blood work.
I decline the above pre-operative blood work and assume the increased risk this puts my pet under.

Pain medication for your pet

We offer optional pain medication for your pet’s comfort after surgery. This speeds healing time and makes your pet more comfortable. *

I agree to pain medication for my pet.
I decline pain medication for my pet.

HomeAgain Microchip

Microchipping saves lives. The new HomeAgain is designed to further increase the chance of reuniting you with your lost pet. *

I agree to microchip my pet.
I decline to microchip my pet.

Owner Release

You are to use all reasonable precaution against injury, escape or death of my pet. I understand that all anesthesia and surgery involves some risk to my pet, and you will not be held liable or responsible in any manner whatever or under any circumstances in connection therewith as it is thoroughly understood that I assume all risks. *

I have read the foregoing and agree.

Owner / Agent Signature *

Clear Signature

By signing above, I agree that I am the owner/agent of the pet listed above and have read, understand, and agree to all terms completed on this form.

Date *

Phone number where you can be reached while your pet is sedated: *

Message

Surgery Treatment & Anesthesia Release Form