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:
- 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: DH2LPPC____Rabies____Bordatella____Lyme____
- 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____
Number where I can be reached between 9am and 5pm today: ________________________________________________