Elective SURGICAL RELEASE FORM

    Thank you for electing to have your pet’s surgical, dental or other stated procedure(s) performed with Family Pet Hospital. To make the procedure as safe as possible, it is necessary for your pet to have the pre anesthetic blood profile to ensure your pet is healthy enough to withstand the performing the described procedure(s). These blood tests, performed here in the clinic in approximately 20 minutes, are used to evaluate kidney/liver function. These tissues play a vital role in ridding the body of the drugs used to anesthetize your pet for surgery and healing after surgery. ******* Required for pets over 7 years of age*******
  • This screens for heart rate and rhythm abnormalities which could affect anesthesia.
  • Oral meds to go home - $16.50-30
  • I understand that an additional pain injection will be administered if deemed necessary by the attending veterinarian for the stated procedures above at an additional cost of $35.99.

    Your pet(s) must be free of fleas and ticks. Otherwise they will be treated at an additional charge to you. All pets must be current on their annual vaccinations, including Rabies, Bordetella (within 6 months) and distemper/parvovirus.
  • I the undersigned do herby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do herby authorize Dr. Jim Burchett and/or his associates and authorized agents to perform said surgical and/ or anesthetic procedure described on my pet and to perform any other procedure or medical treatment deemed necessary by the veterinarian to preserve the life of my pet and will be responsible for the costs of such. I understand that preventative measures will be taken to prevent any unforeseen complications, however by signing this release form I understand the risks involved with anesthesia and surgical procedures on my pet and do herby release the said doctor/agents and authorized servants from any liability arising from said surgery and/or anesthesia on my pet.
  • ALL SERVICES MUST BE PAID IN FULL BEFORE PET IS RELEASED
  • This field is for validation purposes and should be left unchanged.