Pet's Name

Best Contact Number

for day of procedure

Secondary Contact Number

If other, please describe

Have there been any changes to your pet's health since their last exam?

Please list all medications or supplements that your pet currently takes.

Are there any other services your pet needs while under anesthesia?

Anything else you would like to discuss at drop off?

I understand that there may be restrictions to my pet’s activity and agree to follow the recommended post-operative instructions after this procedure.

I understand that if pre-anesthetic bloodwork panel has not been completed within 90 days, a panel will be run pre-operatively as per hospital protocol.

I understand that payments are due at the time my pet is released from the hospital.

I do hereby certify that I am the owner or authorized agent for the owner of the animal described above and that I request, consent and authorize the veterinarians and staff of Daniel Island Animal Hospital full and complete authority to perform the anesthetic procedure listed above. During a surgical procedure at the veterinarian’s discretion, procedures that may benefit the health of my pet, including the extraction of deciduous teeth and/or umbilical hernia repair if hernia is present, may be performed if deemed medically necessary. I understand that all reasonable precautions will be taken to ensure the safety of my pet. I acknowledge that no procedure is without risk. I understand that there is risk of adverse reactions, including but not limited to respiratory or cardiac complications, prolonged recovery, or in rare cases, death. I will not hold the veterinarian or staff liable for unforeseen complications. I also understand that surgical results cannot be guaranteed. Due to the inherent risks of anesthesia, an IV catheter is placed during surgical procedures including but not limited to spay and neuter surgeries and dental procedures. I understand that if an IV catheter is required, for the IV catheter to be inserted the surrounding hair must be shaved to maintain sterility.

Anesthesia release Form