Surgery Anesthesia Release Form Owner's Name* First Last Pet's Name*Date* Date Format: MM slash DD slash YYYY As the owner or agent of the above animal, I hereby give my consent to Lake Palestine Animal Hospital to perform the following procedure:*Pre-Anesthetic blood work: Untreated periodontal disease often results in infection and/or bacteria filtering into the blood stream, which can have long term and severe effects on the organs. Our doctors recommend that preanesthetic lab work prior to the administration of anesthesia to help detect any underlying problems such as but not limited to anemia, dehydration, diabetes, kidney disease and liver disease.*YES, I would like preanesthetic blood work for ADDITIONAL FEE of $95.00 - $110.00 (Basic or Advanced 7 years & older)NO, I understand preanesthetic blood work is recommended for my pet; however I choose to decline at this time.IV Catheter: Placing an IV catheter reduces risk while under anesthesia by allowing us direct access to the circulatory system if needed. This is important because it can be difficult to gain access to a vein in an emergency situation. Giving your pet IV fluid therapy while under anesthesia will help to keep them hydrated as well as keeping their blood pressure stable during the procedure.*YES, I would like an IV Catheter for my pet for an ADDITIONAL FEE of $27.50NO, I do not wish for my pet to get an IV Catheter.Pain Medication (required for ear crops & dewclaw removal): This is a prescription of pain medication that we can send home with you to give your pet in the first few days after surgery. In addition to reducing your pets' pain, the medication will also reduce swelling and inflammation associated with surgery.*YES, I would like my pet sent home with pain medication for an ADDITIONAL FEE OF $20.00NO, I do not wish to have pain medication sent home for my pet.Home Again Microchip Implantation & Enrollment:*YES, I would like my pet implanted with an identification microchip for an ADDITIONAL FEE OF $45.00NORetained Deciduous Teeth (Puppy Teeth:*YES, I would like my pet's retained teeth to be extracted today for an ADDITIONAL FEE OF $15.00 per toothNOFluoride Treatment (for pets 6 months & older with minimal tartar on teeth):*YES, I would like my pet to receive a fluoride treatment today for ADDITIONAL FEE OF $5.00NOAfter carefully reading and filling out this form, I acknowledge full financial responsibility for all procedures and/or tests I have authorized, and I understand that payment in full will be due at the time I pick up my pet. I also understand that any surgical procedure involves a certain amount of risk. By typing your name in the box constitutes a valid electronic signature and with the submission of this form shall act as your legal signature.Signature*Type your name aboveDate* Date Format: MM slash DD slash YYYY Where can we reach you today if needed:Phone #1*Phone #2
