Treatment Release Form"*" indicates required fieldsName* First Last Email* Phone*Pet Name*Requested Surgery or Procedure*Please list anyone who is authorized to pick up your pet*Emergency Contact Name* First Last Emergency Contact Cell Phone Number*Medical InformationDoes your pet have any known medical issues or showing any signs of illness?* Yes NoDoes your pet take any medications?* Yes NoIf yes, please list the medications your pet receives.Has your pet had any previous reactions to anesthesia?* Yes NoPlease state when your pet last ate.*Who is your pets primary veterinarian?* Dr. Dowell Dr. Riley Dr. Ratekin Enter NameEnter your primary veterinarians name.Please list any behavioral concerns (biting, timidness, special handling)*Please list any information we should know about your pet, such as past surgeries*Please list any belongings that will be left with your pet*Authorization & Release of LiabilityPlease review our policies and procedures, then consent at the bottom.As with any procedure requiring general and/or local anesthesia, there are certain risks that serious complications or even death may result. To minimize the risk of such occurrences, we mandate baseline bloodwork be performed in order to assure proper organ function, clotting ability, detect anemia or infection, baseline for future reference. The complete blood count (CBC) is a more sensitive indicator of disease than the physical exam. Additionally, white blood cells (WBCs) and platelets can change within hours due to acute infectious diseases. Abnormal glucose levels can increase anesthetic risk and differ markedly between fasted and non-fasted samples, breeds, age, and sick and healthy patients. Evaluating electrolytes, hematocrit and total protein in fasted patients is essential for monitoring during anesthesia, minimizing the risk of arrhythmias and hypotension, and facilitating patient recovery.As the owner of the above pet, I certify that I am over the age of 18; and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. As with all anesthetic, treatment, and/or surgical procedures, I understand there are risks inherent in these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results. I also understand my pet must have a current physical exam and be up-to-date on distemper, parvovirus, and rabies. For pets 7 years of age or older, the veterinarian may deem additional treatment and pre-surgical procedures necessary for the procedure. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgement. I accept responsibility for any result in additional charges. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment, and hospitalization.While I accept that all procedures will be performed to the best of the abilities of the staff at this facility, I understand that veterinary medicine is not an exact science and that no guarantees have been made regarding the outcome of this/these procedures. I have read and understand the nature of the above procedures and accept the specific terms and conditions set forth herein.I have read and agree to the policies and procedures for anesthesia, surgery, and/or treatment and have verified all information listed above.* Yes NoCAPTCHAΔ
