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Surgery/Procedure Release Form

ANIMAL HOSPITAL OF SAN ANTONIO

2210 NW LOOP 410

SAN ANTONIO, TEXAS 78230

210 344-9741

210 344-0501 fax

SEDATION/ANESTHESIA/SURGERY RELEASE FORM

DATE______________

CLIENT NAME _________________________________________________________________________

PATIENT NAME ________________________________________________________________________

PROCEDURE(S) _______________________________________________________________________

ADDITIONAL INSTRUCTIONS _____________________________________________________________

TELEPHONE NUMBERS FOR TODAY______________________________________________________

I hereby give my permission to the Doctor(s) and Staff of the Animal Hospital of San Antonio to perform the above procedure(s). I understand that sedation and/or anesthesia will be necessary in order to perform the(se) procedures(s). I understand that any time sedation, anesthesia, or the above listed medical procedure(s) are performed there is some risk to my pet. I realize that no guarantee can ethically be made regarding the results of the(se) procedure(s). I understand that I assume financial responsibility for all services rendered and that payment is due on the date of the surgery.

Medication for surgically related pain is not an option.

YES _____ I give my permission to make any necessary change(s) to the(s) procedure(s)

or 

YES _____ I wish to be notified before any changes are made in the above procedure(s).

YES _____ I agree to the following additional procedure(s):

_____ Pre-anesthetic blood profile (recommended for all patients)

_____ Geriatric blood profile (recommended for all patients over 8 years old)

_____ Pre-anesthetic ECG (cardiac patients)

_____ Pre-anesthetic radiographs

_____ ECG monitoring during procedure.

I understand that the above are additional laboratory services and are not included in the cost of the basic procedure.

______________________________________________________________________________________

OWNER'S SIGNATURE                                                                               DATE

______________________________________________________________________________________

AGENT’S SIGNATURE                                                                                DATE

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Office Hours

Our Regular Schedule

Monday:

8:00 am-5:30 pm

Tuesday:

8:00 am-5:30 pm

Wednesday:

8:00 am-5:30 pm

Thursday:

8:00 am-5:30 pm

Friday:

8:00 am-5:30 pm

Saturday:

8:00 am-12:00 pm

Sunday:

Closed