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 No Is your pet taking any medications? Yes No Did he/she receive the medication this morning? Yes No Has your pet experienced any unreported illness or injury in the last 30 days? Yes No Are you aware of any seizures or problems with anesthesia in the past? Yes No The best number to contact me at is*Which is my:* Home Phone Work Phone Cell Phone I will be at this number* All Day In/Out AM PM Section II: Procedures to be PerformedI authorize and direct the veterinarians and staff of Bronx Veterinary Center to perform procedures checked below: Spay Yes No Dental Yes No Anesthesia Yes No Hospitalization Yes No IV Catheter/Fluids Yes No Blood work/Urinalysis Yes No Subcutaneous Fluids Yes No Microchip Yes No Neuter Yes No Other Surgery Yes No Other Surgery Pre‐Anesthetic Bloodwork Yes No Radiographs Yes No Biopsy Send/Don’t Send Yes No Symptomatic Treatment Yes No Urinary Catheterization Yes No Pre‐Anesthetic Bloodwork – Evaluation of basic liver/kidney functions and blood sugar levels. Accept: Yes No N/A Admitting Technician Anesthetic 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 number
