Elective SURGICAL RELEASE FORM Which location is this for?*Please SelectFamily Pet Hospital Exit 11Tiny Town Animal Clinic Exit 1Name* First Last Email Enter Email Confirm Email What Procedure(s) is your pet Having today?*WHEN DID YOUR PET EAT LAST?*Pre-Anesthetic Bloodwork*Yes, I want the pre-anesthetic bloodwork performed on my pet, for an additional fee of $112.50No, I do Not want the pre-anesthetic profile performed on my pet.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*******IV Catheter and fluids-$59.00*AcceptRefuseECG- $80.00*This screens for heart rate and rhythm abnormalities which could affect anesthesia.AcceptRefuseMicrochip- $35.00 (with sedation)*AcceptRefusePain Management*Oral meds to go home - $16.50-30AcceptRefuse**Has your pet had any medication today?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.Signature*ALL SERVICES MUST BE PAID IN FULL BEFORE PET IS RELEASEDDate* Date Format: MM slash DD slash YYYY Best Contact Number:*PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.