Surgical Release Form Client Name* First Last Pet Name*Date* MM slash DD slash YYYY Section I: Information and Anesthetic ReleaseDid you pet eat this morning? Yes NoIs your pet taking any medications? Yes NoDid he/she receive the medication this morning? Yes NoHas your pet experienced any unreported illness or injury in the last 30 days? Yes NoAre you aware of any seizures or problems with anesthesia in the past? Yes NoThe best number to contact me at is*Which is my:* Home Phone Work Phone Cell PhoneI will be at this number* All Day In/Out AM PMSection II: Procedures to be PerformedI authorize and direct the veterinarians and staff of Bronx Veterinary Center to perform procedures checked below:Spay Yes NoDental Yes NoAnesthesia Yes NoHospitalization Yes NoIV Catheter/Fluids Yes NoBlood work/Urinalysis Yes NoSubcutaneous Fluids Yes NoMicrochip Yes NoNeuter Yes NoOther Surgery Yes NoOther SurgeryPre‐Anesthetic Bloodwork Yes NoRadiographs Yes NoBiopsy Send/Don’t Send Yes NoSymptomatic Treatment Yes NoUrinary Catheterization Yes NoPre‐Anesthetic Bloodwork – Evaluation of basic liver/kidney functions and blood sugar levels. Accept: Yes No N/AAdmitting TechnicianAnesthetic Release:I understand that during the performance of the following procedure(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedures, or even procedures different from those set forth previously. I hereby consent and authorize the performance of such procedures as necessary and desirable in the exercise of the veterinarian’s professional judgment. I have been advised of the nature of the services and procedures as well as the risks involved, and while I expect all procedures to be performed to the best of the staff’s abilities, I realize that medical results cannot be guaranteed. I further recognize that a stay in a veterinary hospital can be stressful for my pet, and I authorize the use of anti‐anxiety medication (such as valium) to calm my pet if indicated and agree to pay for the anti‐anxiety medication. I authorize Stephen Katz, VMD, and/or his agents to perform any diagnostic, therapeutic, anesthetic, emergency, and surgical procedures necessary for treating and maintaining my pet’s health and well being. I expect Dr. Katz and/or his agents to use reasonable precautions to ensure my pet’s safety, and I agree to pay in full when my pet is discharged (unless other arrangements have been made). I agree not to hold liable The Bronx Veterinary Center or any of its agents in any way. I understand that it is my responsibility to pick up my pet when advised by the BVC and will be charged for any additional stay/care.Signature of owner/agent:*If I am unreachable, please try this person First Last at this phone numberΔ