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Surgical Release Form

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Surgical Release Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 801-763-1900 for a faster response.

Medical History

Pre-surgical assessment - based on medical history (DR TO DETERMINE)
Grade 1 - Normal Patient with NO organic disease
Grade 2 - Patient with Mild Systemic Disease
Grade 3 - Patient with Severe Systemic Disease Limiting Activity but not incapacitating
Grade 4 - Patient with incapacitating systemic disease that is a Constant Threat to Life
Grade 5 - Moribund, Patient Not Expected to live 24 Hours With or Without Surgery
Surgical Procedures at no additional charge.As with any surgery requiring general anesthesia, there are certain risks that serious complications or even death may result. To minimize the risk of such occurrences, we offer the following:
Anesthetic Safety Screen: Presurgical labwork is advised to any patient undergoing anesthesia under the age of 7 years old. Pricing is on you estimate. To assure proper organ function, clotting ability, dectect anemia or infection, baseline for future reference. The complete blood count (CBC) is a more sensitive indicator of disease than the physial exam. Additionally, white blood cells (WBCs) and platelets can changes within hours due to acute infectious diseases. Abnormal glucose levels can increase anesthetic risk and differ markedly between fasted and nonfasted samples, breeds, age and sick and healthy patients. Evaluating electrolytes, hematocrit and total protein in fasted patients is essential for monitoring during anesthesia, minimizing the risk of arrhythmias and hypotension and facilitating patient recovery.
E-Collar: E-collar is a preventative measure strongly advised to help keep your pets surgical incision safe from self trauma post-opperatively. Keeping the incision safe from trauma allows it to heal faster and help allow your pet to return to normal activity as soon as possible
Home Again Microchip ID: A “Home Again” Microchip is optional and the cost is provided on your estimate. You may think that your pet is protected from getting lost. But accidents happen, and some things-like hurricanes and other natural disasters-are out of your control. In fact, one in three pets will come lost during their lifetime.
As the owner of the above pet, I certify that I am over the age of 18 and I authorize the staff of this hospital to perform the procedure(s) listed above, as well as those deemed necessary to treat life-threatening emergencies. As with all anesthetic, treatment and/or surgical procedures, I understand that there are risks inherent to these services. I acknowledge that staff members at this practice have explained the procedures to me, answered questions to my satisfaction and cannot be held responsible for any unforeseeable results. Further, I understand that I am financially responsible for all costs incurred during this surgery, treatment and hospitalization.
If medications are required, they may be at an additional cost, please understand every patient and situation is different and medications can not always be predictive ahead of the procedure time.
Cost $51
Clear Signature
By signing this form I agree to pay for the services incurred while my pet is in the care of the Country View staff. I understand that anesthesia comes with risks associated, even in a healthy pet.