Home Anesthesia Release

Anesthesia Release

Pet's Name

Owner's Name

Breed

Color

Sex

Age

Surgical Procedure

Name

Dose

How often and last time given

Food

Last Meal/Food Good at

Special Diet

Additional Procedures: (toe nail trim, sanitary shave, etc.)

All anesthetic procedures require pre-anesthetic blood work. This is not optional and is by doctor discretion only.

If my pet is prescribed oral medication to be given at home, I would prefer:

Pills

Liquid

We cannot foresee all problems that arise during surgery, so we ask that you check one of the following:

Perform whatever procedures are needed

Please call me with an estimate if any additional procedures are needed.

I will be available at the following number

If for some reason I am not available when you call, please:

Perform whatever procedures are as needed

Cardiopulmonary Resuscitation $321.67

Do only what I have authorized. I understand that if new circumstances arise that my pet may need to undergo another anesthetic procedure to complete treatment.

All pet’s staying with Sam Bass Veterinary Wellness & CTCH will be checked for fleas and if positive shall receive a Capstar.
Cost of this treatment is $15. In order to reduce stress and minimize bacterial infection during blood draws and catheter
placement, we may need to shave a small patch of fur from your pet’s leg and/or neck.
I am the owner or agent for the owner of the animal described on this form and have the authority to execute this consent.

Name

Signature(Required)

Date(Required)

Contact phone #1

Contact phone #2

Anesthesia Release

Surgical Procedure

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512-388-1299

512-388-1299

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