Owner Name *

Pet Name *

Cell Phone Number *

Work Phone Number *

Home Phone Number *

Procedure(s) *

When did you pet last eat? *

Other concerns:

My dog is current on their monthly heartworm preventative *

Yes

If your pet is not current on monthly preventative, we recommend a heartworm test as a positive animal has an increased anesthetic risk. *

I authorize Pittsboro Animal Hospital to perform a heartworm test at an increased cost.

I decline to have Pittsboro Animal Hospital perform a heartworm test. I understand the risk of declining the test.

I certify that I am the owner, or authorized agent for the owner, of the animal described above. I authorize the doctor on duty and assistants to perform the procedures listed above and on the attached estimate, including administration of pain relief medications, sedatives, and/or anesthetics, as well as any necessary and appropriate medical, radiological, surgical, nursing, diagnostic, and/or emergency care for the animal. I have been advised as to the nature of the procedures and the potential risks. I also understand that no guarantee of successful treatment can be made. I have read and understand the reasons for and the risks of the above and attached procedures(s), and assume full financial responsibility for all charges and services incurred to the described animal. *

I Agree

Date *

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Anesthesia/Surgical Release Form

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Anesthesia/Surgical Release Form

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