Email Address

Client Number

Pet's Name

Sex

Species

Time & Date of your pet's last meal?

What type/kind of surgery or surgeries is your pet having today?

SURGERY RELEASE AUTHORIZATION

I, being responsible for , have the authority to grant The Uptown Veterinary Hospital my consent to receive, transport, prescribe for, treat, and/or operate upon. I understand that during the performance of the foregoing procedure(s) or operation(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or operation(s) or different procedure(s) or operation(s) than those set forth. Therefore, I hereby consent to and authorize the performance of such procedure(s) or operation(s) as are deemed necessary and desirable in the exercise of the veterinarian’s professional judgment. I also authorize the use of appropriate anesthetics and other medications used by the veterinarian. I understand that hospital support staff will be employed as deemed necessary by the veterinarian. I have been advised of the nature of the procedure(s) and/or operation(s) and of the risks involved. I understand that the results cannot be guaranteed. Payment is required in full when pet(s) is released/discharged from the hospital. I have read the above, understand and agree to this authorization and consent form. If you agree to the terms above please provide your name & date.

Surgery Release Form

NEEDED FOR ANY ANESTHETIC PROCEDURE

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