Surgery Release Form in McMurray, PA | Hidden Valley Animal Clinic

Client Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Client Phone*

Pet's Name*

Phone number you can be reached at on the day of the surgery

Surgery to be Performed*

PLEASE READ THE FOLLOWING VERY CAREFULLY

the lack of response on any service option will indicate that service is to be performed

I am the owner (or agent) of the above-mentioned pet, and am not a Minor. I authorize and request you to hospitalize this pet for the purpose of diagnosis, treatment, or surgery procedures, and approve the use of whatever anesthetics you deem advisable for the well-being of my pet. I understand that you will use responsible precautions to assure the animal's safety while in your care, but will not hold you responsible, and I absolve you of all liability arising from the performance of procedures requested herein.

I agree to pay for all services described and to pay for the services rendered due to medical/surgical complications, or unforeseen circumstances. I am aware that there is NO CREDIT. Direct payment will be made. There may be additional charges if all tests and procedures have not been entered. These charges will be billed by mail and payment is expected within 30 days of billing. There will be an additional 1.5% finance charge (minimum of $1.00) added per month on the balance due. A $38.00 collection fee will be added to any balance sent to our collection service.

If your pet is admitted to the hospital with fleas, the staff will treat your pet with a monthly topical flea preventative for an additional charge.

Treatments(i.e. bandages and medications), X-ray, and laboratory procedures rendered after the patient has been released from the hospital are not included in the cost of fees charged for the original episode and will be paid for as separate episodes.

Pre-Anesthetic Blood Testing - Consent Waiver

Like you, our greatest concern is the well-being of your pet. Before putting your pet under anesthesia, we prefer to perform a full blood analysis. Blood chemistry tests give us an inside look at your pet's vital organs and let us know if they are functioning normally. Such tests are especially important before any kind of surgery.

An aging pet's organs will deteriorate, and may lose their ability to function properly. Routine preventive testing for early detection allows us to help live a longer, healthier, happier life. The tests give us a look at 's overall health status, from liver to kidney levels. Just because your pet may be young or look healthy, does not mean that the organs are functioning properly.

These tests are recommended on ALL pets and are HIGHLY RECOMMENDED on pets 6 years and older.*

Yes, I would like bloodwork performed

No, I would not like the recommended bloodwork performed

Post-Operative Pain Medication

Pain medication is often given to our hospitalized patient immediately following a surgical procedure. While many pets exhibit minimal discomfort following surgery, we find that additional pain medication in the days following surgery can often be beneficial in the recovery process. The strength and duration of the medication will vary depending upon the procedure and our assessment of the individual's needs.

Elizabethan Collar (E-collar)

If applicable, an e-collar will be sent home with your pet after surgery. E-collars help prevent your pet from reaching their surgery incision which can prevent additional post-op problems and costs such as incision repair. At your own discretion, you can choose not to use it or use a different kind of collar, however one from the clinic will be sent home.

I acknowledge that I have been advised to use an Elizabethan Collar to prevent injury after surgery and release Hidden Valley Animal Clinic from any liability or responsibility resulting from my failure to do so.

Initial

Additional Services

Microchip - Microchipping is the latest form of permanent identification and is done by injecting the chip with a syringe. A large needle is needed, but the procedure is painless and convenient under general anesthesia.

Topical Fluoride Treatment for Teeth - Fluoride treatment of your pet's teeth at the time of spaying/neutering (the pet must be at least 6 month old) can give permanent benefits from hardening of the tooth enamel and in older pets can increase resistance to tooth decay and decrease dentinal sensitivity.

Microchip*

Yes

Fluoride*

Yes

For 's your pet’s health, vaccines should be current. Pennsylvania State Law requires that all dogs and cats older than 3 months of age be current on Rabies vaccine.

Is your pet current on the rabies vaccination? If not, we will vaccinate your pet for rabies while here for surgery. If your pet was vaccinated elsewhere we will need to see a rabies certificate.

Yes

Date of rabies vaccination?

Would you like your pet to be updated on all recommend yearly vaccines?

Yes

Would you like your dog tested for 4DX Snap Test (4DX - Heartworm / Tick Borne Diseases) while here?

Yes

Would you like your cat tested for Felv/Fiv while here?

Yes

If your pet is here for a growth removal, do you want a biopsy done at an additional charge?

Yes

If your pet is here for a bladder stone removal, do you want a stone analysis done at an additional charge?

Yes

If there are any retained baby teeth that will cause a problem in the future, we will extract them while is under anesthesia.

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Hidden Valley Animal Clinic