🐾 Anesthesia Release Form

Please complete this form before your pet’s appointment. Your answers help us provide the best care possible.

Client name

Phone number where you can be reached TODAY

Pet's name

When was your pet last fed?

Please list current medications, including administration of HAPPY PACK medications, when applicable:

Does your pet have any of the following problems?

Coughing

Sneezing

Vomiting

Diarrhea

Seizures

Change in appetite or water consumption

Your pet will be undergoing general anesthesia for a surgical procedure today. In order to recognize any underlying abnormalities your pet may have, we will be performing a pre-surgical blood profile if it has not already been done.

For safety reasons, all anesthetized animals will be monitored with an ECG/Pulse Oximeter. An IV catheter will be placed and your pet will receive IV fluids during the surgical procedure.

Would you like any additional services to be done while your pet is under anesthesia?

Anal gland expression ($41.95)

Ear cleaning ($49.93)

Microchip implantation ($65 includes lifetime registration)

Fluoride Treatment ($8.49)

Tattoo over surgery incision (No charge)

Help protect an important member of your family. Microchipping is the most complete nationwide system for recovering lost or stolen pets. It utilizes a tiny microchip about the size of a grain of rice, which is implanted between the animals shoulder blades. Individual personalized code numbers are registered in a national database. When a lost pet arrives at a participating animal shelter or veterinarian, the code is scanned and the owner is identified immediately.

Authorization

I, the undersigned owner and designated agent hereby authorize the staff of Cherry Creek Veterinary Hospital to perform a procedure requiring general anesthesia of my animal. I understand that there are potential life threatening risks associated with anesthesia. I understand the veterinarian will make every effort to contact me in the case of unforeseen circumstances regarding treatment of an emergency situation, but if unable to contact me, she/he will proceed with any life sustaining procedures. I am aware of the risk involved and release Cherry Creek Veterinary Hospital from any legal and financial responsibilities arising from anesthetic and surgical complications.

I understand that Cherry Creek Veterinary Hospital does not have 24 hour staffing available and that after clinic hours my pet will be unsupervised.

***Please note that any pet admitted into the hospital with fleas will be treated with topical and/or oral medication at the owner's expense.***

Owner or Authorized Agent

Signature