Appointment Date(Required)

Owner Name(Required)

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Patient Name(Required)

Breed

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Sex(Required)

Male

Neutered Male

Female

Spayed Female

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To: Dr. Thomas, Dr. Gaffney, Dr. McPalmer and the staff of Mulnix Animal Clinic,

I am the owner or agent of the above-named animal and have authority to execute this consent. I hereby authorize the performance of the following procedure(s):

Pain medications will be used if necessary. (Additional fees will apply)

Any medication contraindications or allergies?(Required)

Yes

Please specify what contraindications or allergies your pet has(Required)

I authorize the use of the Therapy Laser if indicated ($28.00)(Required)

Yes

Would you like your pet to receive the Home Again microchip for the price of $64.00 plus an $20.00 enrollment fee? ($84.00 total vs $94.50)(Required)

Yes

ANESTHESIA: A physical exam and pre-surgical labwork help us customize an anesthetic plan to minimize risks for your pet. During the procedure we monitor heart rate, blood pressure, respiratory rate, temperature, oxygenation, CO2, and EKG to help minimize risks. Shaving small areas of fur is necessary for accurate readings of necessary vitals. Although rare, skin irritation may occur at shaved sites.

CATHETERIZATION: An IV catheter will be placed to help support blood pressure and internal organs. This also allows immediate access to the vascular system in case of an emergency.

During a dental/surgical procedure the doctor may deem that additional treatments are necessary (such as extractions or dental x-rays) for your pet’s optimum health. If such services are required:(Required)

Please call me before any additional services are performed. I can be reached at the below number between 8:00am and 1:00pm. I understand that if I cannot be reached additional services will not be performed. I understand that an additional anesthetic procedure may be necessary to perform recommended services at a later date.

Please proceed with the services. You do not need to call me. Additional fees over provided estimate may be added to charges that you are responsible for paying for.

Please proceed with services up to an additional amount of $___________ over my estimate. Please contact me if services are over this amount.

Please specify additional amount over your estimate(Required)

For any tooth extraction on the lower jaw there is an inherent risk of jaw fracture. The risk is very low but follow up treatment would be determined by our dental specialist.

I hereby also authorize the use of such anesthetics as you deem advisable and performance of such surgical or therapeutic procedures as you determine to be indicated. I agree to indemnify and hold you harmless from and against any and all liability arising out of the performance of any of the procedures referred to above.

I understand full payment is due at the time services are rendered.

We will take every precaution to keep safe while under anesthesia. Occasionally an anesthetic emergency will arise and additional care will need to be administered. Please review the following options and select one option and initial.

In the event an unlikely emergency should occur with your pet in our care I authorize Mulnix Animal Clinic to initiate emergency treatment. If unable to reach you at the given number below please:(Required)

Proceed with resuscitation

Do not proceed with resuscitation

Proceed with resuscitation up to ______(Required)

Up to $500 additional

Up to $1000 additional

We ask that your pet is fasted for this procedure, please do not give food after 10pm the night prior and no breakfast the morning of, water is ok overnight. Feeding a small meal (1/3 of a normal meal) just before 10pm the night before would be acceptable. Please check with us for specific medication questions in regard to IF/WHEN they should be given.

Do you agree to all of the selected options?(Required)

I agree to all of the selected options.

I do not agree to all of the selected options.

You cannot submit this form until you agree to your selected options

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Phone number for contact today(Required)

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Surgery & Dental Anesthesia Release Form

Expert Veterinary Care in Fort Collins, CO