Surgery Release Form

SURGERY RELEASE FORM

Name of Pet:______________ Date:_
Species: Age:_ Sex:__________

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. Barbara J Wynne, her agents, servants, and/or representatives full and complete authority to perform the surgical procedure described below. I do herby release the said doctor, her agents, servants, or representatives from any and all liability arising from said surgery on said animal. I understand that I will be charged for 1 package of topical flea medication and a dose will be applied if evidence of fleas is found on my pet.

Please Check the Appropriate Procedure:

Surgery:____________

Radiographs and Anesthesia:

Sedation is occasionally needed to obtain a better x-ray. This will add a cost of $40 to $60 to the procedure.

Ovariohysterectomy or Castration: If your pet is Pregnant do you want her spayed?Yes No

There will be an added charge for spaying females that are in heat or pregnant.

Retained deciduous (baby) teeth will be removed unless you specify otherwise. Do Not Remove

Dental Prophy & Extractions:

Lose or rotting teeth cause pain and are a source of infection. They will be removed during the dental.

Advanced dental disease may require a prescription of antibiotics.

There will be an added charge for extractions or antibiotics.

We perform the following services for no charge when your pet is under anesthesia, unless you specify otherwise.

Toe Nail Trim - No Charge

Ear Cleaning - No Charge

We highly recommend the following services to be done. Call for additional costs.

Canine Vaccinations: DH2LPPCRabiesBordatellaLyme

Feline Vaccinations: FVRCP FELV Rabies

Feline FIV/FELV Test: Yes No

spread by direct contact with infected cat

recommended for all newly aquired kittens and all outdoor cats

Junior Wellness Bloodwork: Yes No

10% of young, active pets have been found to have illnesses or disease on routine bloodwork.
Includes Free heart worm test.
Senior Wellness Bloodwork: (8 years & older) Yes No

40% of strong, active, pets have been diagnosed with progressive and potentially fatal illnesses.

Early detection has improved the outcome at significantly decreased cost.

Avid Microchip: Yes No

allows the safe return of your lost or stolen pet

Dental Prophy With Surgical Procedure: Yes No

Tartar and gingivitis lead to tooth decay and painful teeth

Infected teeth are the leading cause of heart and liver disease

IV Catheter: Yes No

Allows us to give fluids to keep blood pressure up during surgery

Allows for faster deliver of emergency medications if problems occur with your pet

Requires the clipping of hair on the front leg. On rare occasions hair may not grow back or become discolored

I will be paying today with Cash Check Credit Card

Signed_

Number where I can be reached between 9am and 5pm today: __________________________