Anesthesia Release Form

Date*

Pet(s) Name*

Procedure(s)*

Did your pet eat today?

Yes

No

Has your dog been tested for Heartworm Disease in the past 12 months?

Yes

No

Has your pet been tested for intestinal parasites in the past 6 months?

Yes

No

Does your pet have any health problems (Epilepsy, Diabetes, etc.)?

Yes

No

Have you ever been told that your pet had problems with anesthesia or any medication?

Yes

No

Has your pet been vaccinated in the past 12 mos.?

Yes

No

Preoperative Blood Testing - No anesthetic is without risk, we recommend this test, just as your doctor would recommend for you. This test screens your pet for hidden problems that may complicate the anesthesia or surgery. The cost is $168.10 if your pet is in good health and under 7 years of age. If your pet is over 7, a more in-depth panel is performed, costing $203.85. Both of these tests include a chemistry panel and complete blood count.*

Yes, I would like this recommended test performed

No, do not perform test. I understand that serious complications could arise if my pet has an underlying medical condition

Therapeutic Laser Treatment - Greatly reduces pain and inflammation and accelerates healing. This procedure is NOT recommended for mass removals or where there may be abnormal cells. This cost is $64.06.*

Yes, please perform Laser Therapy

No, do not perform Laser Therapy

Intravenous Fluid Administration - IV fluids are included and recommended in all general anesthesia procedures. Exceptions are cat neuters and SPCA procedures, in which case they are recommended but not required. IV catheter administration and first liter of fluids if elected, for those non-mandatory intravenous fluids, the cost is $144.02.*

Yes, please administer IV fluids

No, I understand the risks involved but decline the use of IV fluids

Pain Medication - The patient is given an opioid before surgery as a pre-medication that lasts 4-8 hours. Additional pain medication after surgery is strongly recommended for all procedures, including dentals. This medication is an anti-inflammatory that helps with the healing process, reduces inflammation, and lowers the risk of licking. The cost is $52.10-$69.80 depending on pet's weight and pain medication administered.*

Yes, please give additional pain medication to my pet

No, do not give additional pain medication

Microchip - While your pet is under anesthesia, we offer 24PetWatch microchipping services. This increases the chances of recovering your pet if they ever get lost. The cost is $98.12.*

Yes, please microchip my pet

No, do not microchip my pet

Hip Screen - While anesthetized, a pelvic radiograph screens for early hip dysplasia. If your breed is prone to hip dysplasia, this is highly recommended. There are treatments effective, if diagnosed early. The cost is $119.19.*

Yes, please radiograph

No, do not radiograph

Is your pet on Heartworm Prevention?*

Yes

No

If yes,

Brand:
Last dose given:

Is your pet on Flea/Tick prevention?*

Yes

No

If yes,

Brand:
Last dose given:

Is your pet on any daily medications or have had any medications in the last 3 days?*

Yes

No

If yes, please list them as well as when the last dose was given

Do you need us to call if there are any extractions?
* Please note that your pet will be under anesthesia when we call you so, please be available to answer our call. We only extract teeth that are loose, have exposed roots, severe gum recession, have deep pockets, etc.
*

Yes

No

If we are unable to reach you, may we proceed with extractions we feel are necessary?*

Yes

No

If yes, verify phone number

Would you like to have the SANOS Treatment, which will help keep the gumline free of plaque for up to 6 months? The cost is $129.55.*

Yes, please apply

No, do not apply

Are we removing any masses today?*

Yes

No

If yes, verify location(s) of masses to be removed

Would you like the mass sent out for histopathology?

Yes

No

I authorize Coastal Animal Hospital to perform such diagnostic, therapeutic, and surgical procedures as are in their opinion necessary and advisable for treatment and maintenance of my pet’s health and well-being, including, but not limited to the administration of anesthesia and the performance of surgical procedures. I expect all procedures to be done to the best of the abilities of the professional staff.

I realize that no guarantee or warranty can ethically or professionally be made regarding the results or cure. I also authorize the veterinarian and staff, to provide veterinary services as requested or in emergency circumstances, to follow through with such procedures as are necessary for the well-being of my pet.*

Yes, I understand

I understand that the fees due for my pet’s care will be paid in full at the time of discharge.*

Yes, I understand

Date*

Pet(s) Name*

Procedure(s)*

Did your pet eat today?

Has your dog been tested for Heartworm Disease in the past 12 months?

Has your pet been tested for intestinal parasites in the past 6 months?

Does your pet have any health problems (Epilepsy, Diabetes, etc.)?

Have you ever been told that your pet had problems with anesthesia or any medication?

Has your pet been vaccinated in the past 12 mos.?

Therapeutic Laser Treatment - Greatly reduces pain and inflammation and accelerates healing. This procedure is NOT recommended for mass removals or where there may be abnormal cells. This cost is $64.06.*

Microchip - While your pet is under anesthesia, we offer 24PetWatch microchipping services. This increases the chances of recovering your pet if they ever get lost. The cost is $98.12.*

Hip Screen - While anesthetized, a pelvic radiograph screens for early hip dysplasia. If your breed is prone to hip dysplasia, this is highly recommended. There are treatments effective, if diagnosed early. The cost is $119.19.*

Is your pet on Heartworm Prevention?*

If yes,

If your pet is found to have fleas, we will administer a flea medication at your cost to keep our hospital flea free.

Is your pet on Flea/Tick prevention?*

If yes,

Is your pet on any daily medications or have had any medications in the last 3 days?*

If yes, please list them as well as when the last dose was given

Dentals

Do you need us to call if there are any extractions?
* Please note that your pet will be under anesthesia when we call you so, please be available to answer our call. We only extract teeth that are loose, have exposed roots, severe gum recession, have deep pockets, etc.
*

If we are unable to reach you, may we proceed with extractions we feel are necessary?*

If yes, verify phone number

Would you like to have the SANOS Treatment, which will help keep the gumline free of plaque for up to 6 months? The cost is $129.55.*

Mass Removals

Are we removing any masses today?*

If yes, verify location(s) of masses to be removed

Would you like the mass sent out for histopathology?

I understand that the fees due for my pet’s care will be paid in full at the time of discharge.*

Digital Signature*

Anesthesia Release Form

Date*

Pet(s) Name*

Procedure(s)*

Did your pet eat today?

Has your dog been tested for Heartworm Disease in the past 12 months?

Has your pet been tested for intestinal parasites in the past 6 months?

Does your pet have any health problems (Epilepsy, Diabetes, etc.)?

Have you ever been told that your pet had problems with anesthesia or any medication?

Has your pet been vaccinated in the past 12 mos.?

Therapeutic Laser Treatment - Greatly reduces pain and inflammation and accelerates healing. This procedure is NOT recommended for mass removals or where there may be abnormal cells. This cost is $64.06.*

Microchip - While your pet is under anesthesia, we offer 24PetWatch microchipping services. This increases the chances of recovering your pet if they ever get lost. The cost is $98.12.*

Hip Screen - While anesthetized, a pelvic radiograph screens for early hip dysplasia. If your breed is prone to hip dysplasia, this is highly recommended. There are treatments effective, if diagnosed early. The cost is $119.19.*

Is your pet on Heartworm Prevention?*

If yes,

If your pet is found to have fleas, we will administer a flea medication at your cost to keep our hospital flea free.

Is your pet on Flea/Tick prevention?*

If yes,

Is your pet on any daily medications or have had any medications in the last 3 days?*

If yes, please list them as well as when the last dose was given

Dentals

Do you need us to call if there are any extractions? * Please note that your pet will be under anesthesia when we call you so, please be available to answer our call. We only extract teeth that are loose, have exposed roots, severe gum recession, have deep pockets, etc.*

If we are unable to reach you, may we proceed with extractions we feel are necessary?*

If yes, verify phone number

Would you like to have the SANOS Treatment, which will help keep the gumline free of plaque for up to 6 months? The cost is $129.55.*

Mass Removals

Are we removing any masses today?*

If yes, verify location(s) of masses to be removed

Would you like the mass sent out for histopathology?

I understand that the fees due for my pet’s care will be paid in full at the time of discharge.*

Digital Signature*

Do you need us to call if there are any extractions?
* Please note that your pet will be under anesthesia when we call you so, please be available to answer our call. We only extract teeth that are loose, have exposed roots, severe gum recession, have deep pockets, etc.
*