Anesthesia release form



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Date conversion24.11.2016
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Crossroads Veterinary Hospital

1112 Jones Franklin Road

Raleigh, NC 27606

Office: (919)851-8979 Fax: (919)851-7004




ANESTHESIA RELEASE FORM
Pet’s Name:
Procedure:
I certify that I have withheld food from my pet for the past 12 hours .
I understand that it is a policy of Crossroads Veterinary Hospital that all surgical candidates be up-to-date on required vaccinations. Documentation must be provided by drop-off time or my pet will be vaccinated at the expense of the owner.
I understand that my pet’s procedure requires general anesthesia and/or sedation. All precautions will be taken to insure the safety of my pet. However, I have been informed of the possible risks associated with anesthesia, sedation, and that I am responsible for all associated charges. I also understand that the doctor(s) reserve the right to perform lifesaving efforts should complications arise. I officially release Crossroads Veterinary Hospital, P. C. of any liability pertaining to this procedure (before, during, or after surgery).
Pets may appear healthier on physical exam than they actually are. For this reason, pre-anesthetic bloodwork is recommended. The cost of this bloodwork is $27.00

Yes No (please initial)


Home Again Microchips are available to help protect your pet. Insertion is painless during anesthesia. The HomeAgain system is designed to help reunite you and your pet should he/she becomes lost. Please ask a receptionist for the current price of the HomeAgain Microchip and registration.

Yes No (please initial)


For Dentals: We will make every attempt to notify you if the attending Veterinarian needs to perform a tooth extraction. However, in the event you cannot be reached during the procedure, we will proceed with extractions as deemed necessary. There will be an additional charge for extractions.

(your initials)
Your pet will be receiving an extra injection of pain relief for all painful procedures. A cost of $9-$15 may be added to your bill. Do understand pain management may be necessary following any procedure to keep your pet comfortable, and it remains the doctor’s decision to administer it accordingly.
Numbers where you can be reached today:
1)
2)


Owner Signature Date


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