Surgery, Dental & Anesthesia Release Form

Appointment Date*
Date Format: MM slash DD slash YYYY
Owner Info
Name*
First Last
Phone (provide a number you can be reached at between 7am and 1pm)*
Pet Info
Name*
Consent*
To: Dr. Thomas, Dr. Gaffney 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):
Procedures*
- Dental cleaning
- Spay
- Neuter
- Tumor removal
- Dental cleaning AND tumor removal
- Other surgical procedure (specify below)
Other Surgical Procedure
Any known drug/medication allergies?*
- No
- Yes
Medication/Drug Allergy Details
I authorize the use of the Therapy Laser if indicated ($16.00)*
- No
- Yes
Therapy laser is used to help reduce pain and swelling and speed up the healing process.
Would you like your pet to receive the Home Again microchip for the price of $38.00 plus an $20.00 enrolment fee? ($58.00 total)*
- No
- Yes
During a dental/surgical procedure the doctor may deem additional treatments (such as extractions or dental x-rays) necessary for your pet's optimum health. If such services are required:*
- Please call me before any additional services are performed. I can be reached at the number above between 8:00am and 1:00pm.
- Please proceed with the services. You do not need to call me.
Consent*
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.
Consent*
I understand full payment is due at the time services are rendered.
Consent*
I have been provided a copy of my pet’s estimate/treatment plan.
Consent*
The provided Estimate / Treatment Plan only approximates the cost of this visit. It does not include any treatments that may be deemed necessary upon examination and commencement of the included treatments. You (client) will be responsible for all fees incurred during this visit included on or not on the estimate. Be assured that the health of your pet is our highest concern and we will do everything possible to maintain that health. Understand, too, that your consent indicates that you have reviewed and agree to the terms of this estimate / treatment plan. Your consent does not make you responsible for the charges listed on the Estimate / Treatment Plan unless they are performed.
We will take every precaution to keep your pet 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*
- Proceed with resuscitation. In the event an unlikely emergency should occur with your pet in our care I authorize Mulnix Animal Clinic to initiate emergency treatment up to approximately $500 if necessary.
- Do not proceed with resuscitation

Surgery, Dental & Anesthesia Release Form

Owner Info

Pet Info