Surgery Release Form

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Brandon Lakes Animal Hospital Surgery Release

Name *

First

Last

Phone *

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Email *

Pet's name

Procedure Being Performed Today: *

I am the owner/agent of the above-described animal and have the authority to execute this consent. I hereby consent and authorize the performance of the above procedure(s) or operation(s)and authorize the performance of other procedure(s) or operation(s) necessary and desired in the exercising of the veterinarian’s professional judgement. The nature of such service has been described to me to my satisfaction and I realize that no guarantee, or warranty can ethically or professionally be made regarding the results or cure. I understand that surgery carries some risk regardless of health status. I have been advised that there is a risk of death every time an anesthetic is used and that possibility, as small as it may be, has been explained to me. In the event of unforeseen complications to include cardiac arrest, I give permission for the doctors and staff to take reasonable measures in treating my pet and accept all charges that are incurred as a result of such action.

Resuscitation Order

Please read the following carefully and initial next to procedures you wish to be performed in the case of an emergency.

In the event of cardiac or respiratory arrest I authorize the responsible veterinarian to resuscitate my pet by performing one or more of the following procedures:

Yes to resucitation: External Cardiac Massage (CCPR) Cost range $100-$400.
Yes to resucitation: Internal Cardiac Massage Cost Range $1000-$2000
No to resucitation: I consent in the event of cardiac or respiratory arrest that NO attempts to resuscitate my pet be performed.

Post-resuscitation procedure care most likely will include overnight monitoring at a 24-hour emergency facility at additional cost to the pet owner.

Signature *

Clear Signature

I understand that I assume financial responsibility for all services rendered, and that payment is expected on the day of surgery. Any medications and supplies purchased will be at an additional charge.

Date / Time *

Surgery Release Form

Brandon Lakes Animal Hospital Surgery Release

Resuscitation Order

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