Surgical Release Form
Owner:
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Phone number:
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Patient:
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Date:
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Procedure to be performed:
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We give flea control to all pets that are left in our care for pets less than 25 pounds for $5.00 and pets over 25 pounds for $6.00. In the event your animal has both fleas and ticks, we charge $30.00 – $40.00 for the removal of the external parasites. We offer a microchip for all pets at any time for $45.00.
Would you like pre-anesthetic blood work for your pet undergoing anesthesia for $45.00?
Would you like advanced blood work for your pet (if over 6 years old) undergoing anesthesia for an additional $72.00?
Would you like extra pain control to take home for an additional $35.00 – $55.00?
Would you like an extra post surgical pain injection for an additional $30.50 – $50.00?
Anesthetic Risks:
(Although every effort is made to make anesthesia as safe as possible including vital sign monitoring and use of the most up to date anesthetic agents and equipment, understand that anesthesia has inherent risks). The incidence of complications from anesthesia is extremely low and we do not anticipate any in your pet but on rare occasions the following can occur:

1. Allergic reaction to the anesthetic agents
2. Heart rhythm abnormalities
3. Untoward reactions to the gas including drops in blood pressure or respiratory difficulties
4. Just like in humans, on very rare occasions, general anesthesia can result in death

Surgical Risks and Complications:
(5 – 8% of cases)
1. Infection (less than 3%) which may require additional testing and medication at an additional cost.
2. Blood clots that can lodge in major organs causing stroke or rarely death both during or after anesthesia.
3. Allergic reaction to the suture material utilized in the repair or surgical manipulation can cause a seroma to form (small pocket of fluid) which usually resolves over time without drainage or surgery (about 10%). Rarely, some patients develop a suture reaction right after surgery or months to years later that requires suture removal.
I consent to the procedure listed above to be performed on my pet. I understand all the risks and complications that may arise from anesthesia and the surgery.
Signature will be required in person.
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