Surgery Release Form | North Reading Veterinary Clinic

Provide authorization for us to perform anesthesia, surgery, and/or other services for your pet.

Pet Owner Information

Name(Required)

Email(Required)

Phone(Required)

Phone Type(Required)

Pet Information

Pet's Name(Required)

D.O.B.(Required)

Species(Required)

Breed(Required)

Color/Markings(Required)

Would you like us to microchip your pet while under anesthesia for $53.00?

Check the types of medication you are able to give to your pet:

Pills

Capsules

Liquid

None

PRE-ANESTHETIC BLOOD TESTING

Like you, our greatest concern is the well being of your pet. Before putting your animal under anesthesia, we will perform a full physical exam.

However, many conditions, including disorders of the liver, kidneys, or blood are not detected unless blood testing is performed. Such tests are especially important before any kind of surgery.

For these reasons, we highly recommended blood screening before such procedures. The additional cost of this important blood test is _________.

Our laboratory is fully equipped and staffed to perform these blood tests.

Results will be immediately available to examine before anesthesia/surgery.

Would you like your pet to have a pre-anesthesia blood screen?

Owner Authorization

Authorization to perform anesthesia, surgery, and/or other services.

I, the undersigned, do hereby authorize the N.R.V.C. to perform the service(s) listed.

The nature of the service listed above has been described to me and to my satisfaction. I realize that no guarantee or warranty can ethically or professionally be made regards the results or cure.

I assume full financial responsibility for all services rendered, and understand that payment is due upon the discharge of animal described below. I understand that there will be additional charges for dental extractions or other added procedures, the doctor will call to discuss these charges.

Pet Owner Signature(Required)
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