Surgery Release Form – Boerne Veterinary Clinic

The BEST way to reach you: *

Call
Text

Phone *

E-mail

Owner's Name *

First

Last

Pet's Name *

Pet History

Has your pet received any food in the past 12 hours? *

Yes
No

Has your pet received any medications this morning prior to surgery? *

Yes
No

If so, please list medications given: *

Mandatory Services

I understand that all pets will receive pre-anesthetic bloodwork to evaluate organ function and blood cell lines to examine the health of your pet prior to anesthesia. $115 *

I have read and understand.

Intravenous Catheter and Intravenous Fluid Therapy: An intravenous catheter is placed in your pet’s leg. This allows the doctor to have immediate access to the blood stream in case emergency medications are needed and also allows us to administer fluids to maintain hydration and blood pressure. $55 *

I have read and understand.

Optional Services

Microchip Placement and Enrollment Fee: Should your pet become lost, shelters and veterinary hospitals have microchip scanners to retrieve your information to contact you. $55 *

Yes
No

Dental Procedures ONLY

Full Mouth Dental X-rays: Dental X-rays allow us to detect disease below the gumline which can be missed on a visual oral exam.

Approve
Decline

*May not be optional for severe dental disease

During a dental cleaning, your veterinarian may identify a tooth that is no longer healthy and needs to be extracted. Please be available for contact at the number provided above in case your veterinarian needs to inform you of possible extractions. Please check the box below. I authorize any recommended extractions in the event I am unable to be reached. This will add additional costs to the dental procedure.

Yes
No

I understand that anesthesia may involve some risk to my pet. I agree to hold you harmless, in the absence of negligence. In the event complications arise and I cannot be immediately contacted, you are directed to make the decision you deem best for my pet. *

I have read and understand.

Owner's Signature *

Date *