Owner's Name *

First

Last

Email *

Pet's Name *

Are vaccinations current? *

Yes
No

Procedure(s) being performed today: *

Is your pet on heartworm prevention? *

Yes
No

Did your pet eat anything this morning? *

Yes
No

Is your pet allergic to any drugs? *

Yes
No

If yes, please specify. *

Has your pet had any illness (vomiting, diarrhea, etc.) or injury in the past 30 days? *

Yes
No

Does your pet have any history of seizures and/or previous anesthetic problems? *

Yes
No

Is your pet currently on any medications? *

Yes
No

If yes, please specify. *

I understand that I am solely responsible for all charges accrued during and associated with this procedure. I will provide payment-in-full at the time services are rendered and understand that the final cost of this procedure may increase or decrease from the original estimated total based on additional time needed, an increase in severity, and/or other special circumstances. I have discussed the health risks and benefits of this procedure with the veterinarian and authorize payment in full for the specified procedure; even in the event of death. I understand and agree that if my pet is not picked up by the end of the business day, FPAH is authorized to take whatever action is deemed necessary for the continued care of my pet, and I agree to pay for any costs associated with that care. I authorize FPAH to take photographs and videos of my pet for the purpose of education, social media, or other clinic-related uses. No personal information will be released without consent. I understand that the veterinarians at FPAH highly recommend that I conduct pre-operative blood tests to determine if my pet may have unknown disorders of the liver, kidney, blood, and/or other systems. Such disorders may increase my pet’s anesthetic risks. Further, the following conditions increase the possibility of complications or death before, during, or after surgery: Patients that are pregnant or in heat; Patients that are obese or overweight; Patients of advanced age; Patients suffering from disease or injury. The reasonable alternative(s) to the procedure(s) have been explained to me and I authorize moving forward with the above-written services. I certify that my pet has had no food for at least ten (10) hours prior to surgery. *

I understand

I authorize CPR in the case of an emergency. *

Yes
No

Four Paws Animal Hospital will use all reasonable precautions against injury, escape, or death of my pet. I understand that anesthesia and surgery always involve some risk to my pet and I agree to hold Four Paws Animal Hospital harmless, in the absence of negligence, in connection with these procedures. I acknowledge that no guarantee or assurance has been made to me as to the results or outcome of the above procedure(s). In the event complications arise and I cannot be immediately contacted at the below-listed number, you are directed to make the decision you deem best for my pet. I have read and understand all parts of this agreement.

Date *

Contact Phone Number *

Online Forms

Surgery Release Form

online forms

Surgery Release Form

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