Surgery, Dental & Anesthesia Release Form

Appointment Date*

Owner Info

Name*

First Last

Phone (provide a number you can be reached at between 7am and 1pm)*

Co-Owner Info

Name

First Last

Phone

Pet Info

Name*

Consent*

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):

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 ($17.90)*

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 $43.00 plus an $20.00 enrolment fee? ($63.00 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 7:00am 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 for additional fees.
Please proceed with the services. You do not need to call me. I understand additional fees over the provided estimate may be added to charges that I am responsible for paying for
Please proceed with services up to an additional amount over my estimate, that will be specified by me. Please contact me if services are over this amount. I understand that if I cannot be reached, additional services over what I have approved will not be performed. I understand that an additional anesthetic procedure may be necessary to perform recommended services at a later date for additional fees.

Please enter additional $ amount over my estimate:

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.
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 $1000 if necessary.
Do not proceed with resuscitation