STERNER VETERINARY CLINIC

SURGICAL RELEASE FORM

Patient name                                Age,                            Female/Male, Breed

Client name                       Phone number               Client account #              

                                                                                                                        Current weight:_________

Procedures to be performed:

Prior to anesthesia your pet will receive a full physical exam.  Pre-anesthetic blood work is recommended and will be completed before anesthesia to evaluate the overall health of your animal. 

Pre-Anesthetic Blood work  $39.00.    Approve      Decline      Dr. Discretion         
                                                                                   

Pain Medication to go home              Approve      Decline          Dr. Discretion 

Pain medication in hospital included with surgery               

E-collar to go home $8.00                      Approve     Decline        Dr. Discretion

HomeAgain Microchip $43.50            Approve     Decline        Dr. Discretion

Histopathology  $79.00                       Approve       Decline          Dr. Discretion

Romp/Ket__________/__________      Ace/Morph___________/_________

Torb/Keto___________/_________           Ket/Val ___________/___________

Dom/Antis___________/__________ Polyflex_______________________ 

Buprenex ______________________ Propofol_______________________

Isoflurane                    Atropine____________             Other__________

Water Bottle (<99°F) Post op temp__________

I authorize the above named procedure to be performed at Sterner Veterinary Clinic.  The nature of such service has been described to me to my satisfaction. I realize that dangers of anesthesia and surgery include, but are not limited to, hemorrhage, infection and even death.  No guarantee can ethically or professionally be made regarding the results or cure.  I understand that I assume financial responsibility for all services rendered, and that payment is due on the date of surgery. During non-business hours, no veterinary personnel will be on the premises.

Signature_________________________________________Date  (no appointment)

Phone number where you can be reached from 8am to 11am ______________________

Send me a text message. Cell number__________________  service provider_________

At Discharge: