Alpharetta Animal Hospital Surgery Release

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Owner's Name*

Email address:*

Name of pet*

Species*

Breed

Sex*

Age

Pet History

Is your pet current on vaccines?*

Yes

Is the dog or cat on Heartworm preventative? Heartworm disease is an anesthetic risk.*

Yes

Has your pet been checked for Intestinal Parasites in the last 6 months?*

Yes

Any vomiting, coughing, or diarrhea lately?*

Yes

Did your pet eat after midnight?*

Yes

Is your pet ALLERGIC to any drugs?*

Yes

Has your pet had any illness or injury in the past 30 days?*

Yes

Procedure to be performed:*

Would you like any of the following elective prcedures to be done at the same time:

Do you need a HomeAgain microchip? If the answer is yes, please go to our online HomeAgain registration form and fill it out.

Yes

Teeth Cleaning (Ultrasonic Scaling and Polishing)

Yes

Routine Nail Trim

Yes

Express Anal Glands

Yes

Bath -- Expressing anal glands and nail trim included

Yes

If fleas are seen, give Capstar, a tablet that kills fleas for 24 hours

Yes

Submission of growth to the lab with growth removals

Yes

Other:

PRE-OPERATIVE BLOOD PANEL

REQUIRED FOR ALL ANIMALS OVER 6 YEARS OLD AND STRONGLY RECOMMENDED FOR PETS UNDER 6 YEARS OLD

As part of our commitment to offering the safest care for your pet that we can during its visit for surgery, we will perform a physical examination prior to anesthesia. We strongly recommend that a pre-operative blood screen be performed to insure that the risks of the anesthesia to your pet's health are kept to a minimum. This blood panel allows us to determine if there are any underlying problems that might lead to complications during or after anesthesia, problems which are not always evident on a physical exam.

Pre-Operative Bloodwork: $106.59*

Accept Pre-Operative bloodwork

Decline Pre-Operative bloodwork

PAIN MANAGEMENT

Additional pain control is an option available for your pet. Various forms of pain control are available; the cost will depend on the type of pain control administered and the weight of the pet. Additional pain control is mandatory for all feline declaws.

Additional pain medication.*

YES for additional pain control.

NO I do not want additional pain control

ONLY If recommended by veterinarian

I hereby authorize the use of such anesthetics as you deem advisable and performance of surgical or theraputic procedures as you determine to be indicated. I agree to indemnify and hold you harmless from and against any and all liability arising out of the performance of any procedures listed above.

Please sign on the line:*

Phone number where you can be reached TODAY:*

Emergency contact number*

Alternate person who can be reached in case of emergency: