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Dental/Surgery Release
Patient Name, (canine/feline), Age, Sex , Breed, Color
Client name, phone number Client account # #####
Current Weight____________
Procedures to be performed:
Prior to anesthesia your animal will receive a full physical exam. Pre-anesthetic bloodwork is recommended but not required and will be completed before anesthesia to evaluate the overall health of your pet.
Pre-anesthetic bloodwork –$39.00 � Approve �Decline
Intravenous Catheter and Fluids
Under 35lbs--$47.50/35lb and over--$62.00 �Approve �Decline
Dental extractions – Price variable �Approve �Decline
Post Operative Pain Medication to go home
Medication to go home: Price variable �Approve �Decline
Pain medication in hospital included with surgery
Histopathology-- $79.00 �Approve �Decline
E-collar to go home--$8.00 �Approve �Decline
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 the day of surgery ___________________________
Send me a text message when done Cell number__________________ service provider_________ |
Sterner Veterinary Clinic
821 N Jefferson St Ionia MI 48846 # 616-527-3320