Anesthesia release Form

Your Name

First Name

Last Name

Pet's Name

Best Contact Number

for day of procedure

Type of Procedure

Dental

Spay/Neuter

Mass Removal

Other

If other, please describe

Have there been any changes to your pet's health since their last exam?

Please list all medications or supplements that your pet currently takes.

Is your pet to be microchipped while under anesthesia today?

Yes

Already microchipped

Anything else you would like to discuss at drop off?

I do hereby certify that I am the owner of the animal described above and that I give the veterinarians of Daniel Island Animal Hospital full and complete authority to perform the anesthetic procedure and to perform any other procedure that, at the doctor's discretion, may be useful to promote the health of my pet, including deciduous and adult teeth extractions and/or umbilical hernia repair as deemed medically necessary. I do hereby forever release Daniel Island Animal Hospital, its agents, servants, or representatives from any and all liability arising from said surgery on my animal. Due to the inherent risks of anesthesia, an IV catheter is often placed during this anesthetic procedure. I understand that in order for the IV catheter to be inserted the surrounding hair must be shaved to maintain sterility.

Date

YYYY