Surgery Release Form
Today's Date:
04
/
21
/
2025
Client Name:
Email, just in case:
Contact Phone # for DATE OF SURGERY:
Pet's Name:
Your pet is scheduled to undergo a procedure requiring general anesthesia. The safety of modern anesthesia has improved substantially with increased knowledge, state-of-the-art equipment, and new anesthetic drugs. Anesthesia can never be considered risk free. We offer ways to maximize anesthetic safety by running pre-surgical bloodwork, placing IV catheters and offering pain medications to our patients. Pre-anesthetic bloodwork allows us to evaluate the patient for underlying organ disease and bleeding predisposition that is not apparent on physical exam. Intravenous catheter and fluids are required to maintain blood pressure during surgery, and allow a readily available route for emergency drug administration if a complication occurs. Heart, respiratory and temperature monitors are used on all anesthesia patients.
Yes, I understand the purpose of pre-anesthetic bloodwork for my pet.
My pet's pre-anesthetic bloodwork was done on:
MM
/
DD
/
YYYY
Was your pet's bloodwork completed in-house at CCVS?
Yes
No
Is your pet currently on any medications?
Yes
No
If you answered yes, please list your pet's current medications here
(including the name of the medication and dosage):
Post-operative Pain Medication/Sedation: FYI:
We will be sending home (oral) pain medications with a patient after undergoing any invasive procedure.
Yes, I understand
If you have any questions, please do not hesitate to ask one of the veterinary care professionals. Your veterinarian may have specific requirements based on the procedure and patients needs.
I authorize CCVS to perform the following surgery on my pet referenced above:
Indicate the name of this procedure.
I understand that during the performance of this procedure, unforseen conditions may be revealed that necessitate an extension or variance in the procedure(s) set forth above.(i.e. If any abnormal tissues are encountered during surgery, a biopsy will be taken.) Any additional costs will be discussed before incurring charges. I expect to use reasonable care and judgement in performing the procedure(s). The nature of the procedure(s) and risk involved has been explained to me and I realize results cannot be guaranteed. I am also aware that unforseen events resulting from the procedure(s) will not relieve me from my obligation to all reasonable costs incurred regarding my animal. You are being presented with this form because your pet is undergoing a surgical procedure. While under anesthesia, if your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatment. If either respiratory arrest or cardiac arrest occurs, your pet will die unless immediate resuscitation attempts are started.
I DO give permission to the staff of CCVS to perform CPR (Resuscitation) on my pet if he/she suffers from respiratory or cardiac arrest. I understand this does not guarantee survival, and subsequent arrest episodes may occur. I understand that my pet may die despite CPR. I understand that if my pet survives CPR, he/she may have lasting complications including kidney or brain injury.
I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing and/or his/her heart stops beating that my pet will die unless CPR is performed. I elect DNR (Do Not Resuscitate) orders placed on my pets records OR I elect that the veterinary staff stop the initial attempts of CPR that may have been started while I was being informed of the condition of my pet and my options.
Financial Transactions:
We require a deposit of at least 50% of the provided estimate at the time of your pet’s surgery drop-off .
We accept many forms of payments for service, however we
DO NOT accept checks
at all.
**Any animal found to have fleas or ticks will be treated at the owners expense.
Signature of Pet Owner/Client:
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******IMPORTANT:
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