Surgical & Anesthesia Release Form

Owner(Required)

First Last

Owner's Email(Required)

Pet's Name(Required)

Species(Required)

Pet's Age(Required)

Today's Date(Required)

Month

Day

Year

I do hereby certify that I am the owner/guardian/agent of the pet described above and have full authority to execute this consent. I certify that my pet has not eaten in the last 8-12 hours as recommended. I give my full authorization and consent to t he veterinarians of Arlington Heights Animal Hospital to perform t he surgical procedure(s) listed below.(Required)

I certify and authorize

Procedure(s):(Required)

SAME DAY Pre-Surgical Blood Work(Required)

Your pet’s risk of complications during and after anesthesia and surgery is tremendously greater if there is preexisting organ disease, malfunction, or failure. As a result, our veterinary team requires that blood work be completed within 60 days before anesthesia and surgery to help rule out these problems or identify them and devise an alternative treatment plan to meet your pet’s unique needs. These blood panels provide immensely valuable information. If your pet has had blood work within 60 days, our staff will inform you during your admission appointment. If your pet has not, during the check-in process, we will perform same-day preoperative blood work.

Current (Performed within 60 days of this procedure)

-Pets under 5 years of age: We perform a complete blood count and a blood chemistry profile that assesses the liver, kidneys, and blood glucose. This service will be at an additional cost.

-Pets over 5 years of age: We perform a complete blood count and COMPREHENSIVE blood chemistry profile that assesses the liver, kidneys, blood glucose, blood proteins, calcium, phosphorous, and electrolytes. This service will be at an additional cost.

Initials(Required)

Post-Surgical Pain Management & Antibiotics: The anesthetic protocol chosen by our doctor provides relief from pain during and up to 4-6 hours after surgery. For this reason, your pet should be comfortable, although possibly a little drowsy, upon discharge. IF NEEDED, pain medications, antibiotics and/or sedatives will be sent home to be used after all surgical procedures for continued comfort, safety, and pain relief.(Required)

Initials

– All pets presented for surgery will receive an IV catheter to administer fluids and medications before, during, and after surgery. A small section of hair on the front leg will be shaved for catheter placement as well as sections of hair at the sit~ of the surgery. – Every pet will be monitored by a veterinary technician and an ECG machine through their entire anesthetic procedure.

If for any reason an emergency situation arises with my pet, the doctors and supporting staff of Arlington Heights Animal Hospital Have my full permission to perform any and all lifesaving measures that may result in additional costs.(Required)

Decline

Initials(Required)

I authorize the doctors and support staff of Arlington Heights Animal Hospital to perform services, diagnostic procedures, and treatments deemed necessary to improve my pet’s quality of life and provide quality veterinary care. I have been advised of the risks and possible complications of my pet’s procedure and that results and/or expected outcome cannot be guaranteed. I understand that any anesthesia involves risk to my pet. By signing below, I acknowledge that risk and will not hold the doctors and/or technicians liable or responsible in any matter for any injury, escape, or death of my pet in connection with the procedure. I am encouraged to discuss any concerns I have about these risks with the doctor before the procedure(s) is/are initiated. I understand that payment is due at the time of service and that I am fully financially responsible for any and all services rendered. I also agree to pay for all expenses incurred to collect the debt including, but not limited to, attorney fees, collection agency fees, and billing fees.

Signature of Owner / Guardian / Agent(Required)

Date(Required)

Month

Day

Year

Phone(Required)

Questionnaire & Additional Services

History: To the best of my knowledge, my pet is healthy and has had no signs of illness such as vomiting, diarrhea, coughing, sneezing or weight loss. Otherwise, please list any symptoms and how long you have noted them:(Required)

Please list all medications your pet is on and the last time the medication( s) was/were given:(Required)

If “none” please put none

Is your pet allergic to any medications? If so, please list:(Required)

If “no” please put none

Does your pet have any history of seizures or problems under anesthesia? If yes, please describe:(Required)

If “no” please put none

Initials(Required)

External Parasites & Skin Infections: All pets presented for surgery must be free of external parasites and skin infections. If fleas, ticks, and or ear mites are found, the pet will be treated at the owner's expense. Doctor reserves the right to postpone surgery if a skin infection is present . I understand antibiotics and other treatment may be initiated at additional cost.(Required)

Initials

E-Collar: An e-collar will be sent home for all pets in which one is deemed necessary to prevent injury or infection to procedure site, unless I provide one prior to surgery. This sma ll investment could save the added cost to have the surgery site repaired.(Required)

Initials

Annual and Semi-Annual Services: I understand if my pet is due for any annual or semi-annual services (fecal, vaccines, heartworm test, etc), and they will not interfere with the procedure today, we are authorized to update them at this time, and I understand I will be charged for these services. I also request the following additional services:(Required)

Initials(Required)

Microchip: 1 in 3 pets goes missing during its lifetime, and without proper identification, 90% never return home. A microchip is a form of permanent identification implanted under your pet's skin between the shoulder blades. The microchip is about the size of a grain of rice, is placed in a matter of seconds, and helps keep you connected to the pet you love, forever. Once registered, you can update your pet's online profile to include his/her picture and any pertinent medical information.(Required)

Accept: This service will be at an additional cost

Decline

My pet already has a microchip, please check their chip today

Initials(Required)

Laser Therapy: We now offer laser therapy post operatively which accelerates healing, reduces pain, and reduces inflammation.(Required)

Accept: This service will be at an additional cost

Decline

Initials(Required)

Additional Services for Spay/Neuter:

– If your pet has deciduous (baby teeth) that are not likely to fa ll out, we will extract them to prevent future dental disease. Usually, any deciduous teeth remaining after 6 months will need to be extracted. – If your pet has an umbilical hernia that is reducible, we will repair it during surgery to prevent future emergency. By initialing below, I understand there are additional costs for these services.

Initials(Required)

Dental Exam: (applicable for dental procedures) A full oral exam, including x-rays, is performed with all dental cleanings. If t he doctor finds teeth that are damaged by dental disease or trauma we will extract them. I understand these services will be performed if deemed necessary by the doctor and that there are additional costs for these services.(Required)

Initials

Histopathology: (applicable to growth removal surgeries) Histopathology is the examination of biopsied tissues. It is recommended for all growth removals to evaluate the type of growth and if further treatment is needed post-surgery.(Required)

Accept: This service will be at an additional cost

Decline

Initials(Required)

Pickup: I understand there will be a 5-10 minute consultation when I pick-up my pet with a technician to go over homecare instructions. I will also have time to ask the doctor any quest ions about the procedure if needed. I also understand that there is no treatment staff on the premises after closing hours, on weekends or during holidays. I also understand any pet not picked up by 5:30PM {Mon-Fri) or 12:00pm (Sat) will be kept overnight and and I will be charged a boarding fee. PLEASE CALL AHEAD IF YOU ARE NOT ABLE TO PICK YOUR PET UP BY CLOSING TIME.(Required)

Initials

Were you quoted a price for today's procedure by an AHAH team member? If so, how much?

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