Client Name *

First

Last

Phone Number *

Email *

Pet's Name *

Species *

Canine
Feline

Breed *

Age/Date of Birth *

Sex

Male
Female

Medical History:

Has your pet had any treats or food in the last 8 hours ? *

Yes
No

If so what time ? *

Is your pet experiencing any vomiting, coughing, sneezing, diarrhea ? *

Yes
No

Is your pet taking any medications ? *

Yes
No

If yes, please list : *

Elective procedures to be performed

Express and glands
Clean ears
Nail trim $0
Other

If other, please list : *

Pre-anesthetic bloodwork:
Your pet is scheduled for anesthesia and dental treatment. Any anesthetic procedure has potential risk. Therefore, we recommend a blood profile for all pets and require it for pets over 7 years of age, to ensure that your pet is in suitable condition prior to this procedure. We are able to perform quick and accurate blood tests before your pets anesthetic induction. these tests are same that your doctor would request before you would undergo anesthesia.

Please Choose One *

Recommended pre-anesthetic tests already been completed.
Yes: I hereby consent to the recommended mmended pre-anesthetic tests.
No: I decline the recommended pre-anesthetic tests. I understand the potential risks by omission of these tests. I assume full responsibility for my pet should complication.

If recommended pre-anesthetic tests already been completed, please mention date : *

Intravenous catheter and fluids:
An IV catheter will be placed prior to anesthesia. IV fluids improve blood pressure, assist in processing the anesthetic agents, compensate for blood loss and provide a direct line in case of emergency.

I would like to have microchip placed : *

Yes
No

Emergency Treatment:

In case emergency treatments are required while your animal is in our care. *

I authorize.
I do not authorize Southgate Animal Clinic to perform emergency treatment on my pet.

Please note: Southgate Animal Clinic is not a 24 hour care facility. Pets hospitalized overnight do not receive monitoring between the hours 7.30 pm to 7.30 am.

I agree to the above terms and conditions. I have reviewed the estimate provided to me and I agree to pay the full amount when my pet is discharged from a Southgate Animal Clinic. *

I agree

** All animals found to have an existing flea population will be treated with an appropriate flea product.

Signature *

Today's Date *

Phone

Email

Online Pharmacy

Anesthesia & Surgical Procedure Release Form

Anesthesia & Surgical Procedure Release Form

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Questions?

Location

Contact Information

Hours