Surgery Anesthesia Release Form

What procedure is your pet coming in for?

Did your pet eat or drink past midnight?

Is your pet on any medication?

If yes, what medications?

Do you have any additional concerns today?

If yes, what are they?

Has your pet been coughing or sneezing lately?

Has your pet had any vomiting or diarrhea?

If yes, please explain.

It is understood, for the best interest of my pet that an IV catheter will be placed (Note: A small area of hair will removed from the front left leg due to the placement of the catheter). Intravenous fluids will be given during the procedure to help maintain blood pressure and allow rapid administration of drugs should an emergency situation develop. The catheter and fluids are included in the cost of anesthesia.

I request that you perform anesthesia and/or surgery on my pet. I understand that there is always a risk for anesthesia and surgery. Furthermore, I authorize the hospital staff in an emergency situation, to follow through with such procedures as are necessary for the well-being of my pet on a continuing basis while attempts are made to contact me. I assume full financial responsibility.

If an emergency were to occur under anesthesia, please provide the following CPR: (Circle one please)

0 – Do not resuscitate

1 – CPR Grade 1 (Minimal Attempt; injection) $96.00

2 – CPR Grade 2 (Chest Compressions) $239.50

3 – CPR Grade 3 (Do all that’s necessary, including opening the chest) $529.50


Signature (over the age of 18 years old)


Roya1234 none 8:00 am - 6:00 pm 8:00 am - 6:00 pm 8:00 am - 6:00 pm 8:00 am - 6:00 pm 8:00 am - 6:00 pm 8:00 am - 6:00 pm Closed veterinarian,3,,, #