Surgery Drop Off Form

Client Name:*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

Pet's Name*

Dog or Cat

Please answer the following questions regarding the history of your pet:

Has eaten this morning?*

YesNo

Any vomiting, coughing, or diarrhea noted?*

YesNo

Is on heartworm prevention?*

YesNo

Has your pet been ill or injured in the past 30 days?*

YesNo

Is allergic to any medications?*

YesNo

If so what medications?

In the event of an anesthetic emergency, would youlike for us to perform CPR?*

YesNo

* Labwork is required for all patients undergoing general anesthesia. This price of labwork is incuded in the surgical estimate for you pet.

Would you like any additional procedure(s) done while is under anesthesia? If so, what?

I am the owner/agent for the above described animal and have the authority to execute this consent and authorization of the above named surgery(s

I understand that during the performance of the procedure(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or even different procedure(s), than those set forth previously. I hereby consent and authorize the performance of such procedure(s) as necessary and desirable in the exercise of the veterinarian’s professional judgment. I have been advised of the nature of the procedure(s), as well as the risks involved, and also realize that results cannot be guaranteed. I additionally authorize the use of appropriate anesthesia, pathologist examination of excised tissue as deemed appropriate by the veterinarian, and the administration of other medications, and understand that hospital staff will be utilized as deemed necessary by the veterinarian. I have read and understand this authorization and consent.

My signature below constitutes my acknowledgement that (i) I have read and agreed to the above, (ii) the procedure(s) have been explained to my satisfactionand that I have all the information that I desire, (iii) I have had the chance to ask questions, (iv) I have been given an alternative plan with the inherent risks of selecting the alternative plan, and (v) I authorize and consent to the performance of the procedure(s) listed in the treatment plan (estimate) and to the administration of anesthesia or sedation when deemed necessary.

Telephone number(s) where I can be reached:

Best #*

2nd Best #

Signature

Date*

Date

Eastside Animal Medical Center

Surgery Release Form