Surgery Release Form - BridgeMill Animal Hospital - Canton, GA

BridgeMill Animal Hospital

9560 Bells Ferry Road
Canton, GA 30114

(770)479-2200

www.bridgemillvet.com

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Surgery Release Form

Please make sure to check the caption box and click on the submit form box when submitting online. 

You also have the option to print out the form and manually filling it in to bring with you to the clinic.

Surgery Release Form

Date: (required)

Owner Name: (required)

Street Address: (required)

City/State/Zip: (required)

Best Phone Number: (required)

Pet Name: (required)

Breed: (required)

DOB: (required)

Color: (required)

Consent to Operation, Administration of Anesthetics and the Rendering of other Medical Services:
PROCEDURES REQUESTED WHILE ANESTHETIZED: (required)
Spay (female)
Neuter (male)
Declaw Front
Declaw Back
Declaw Both
Radiographs (X-Rays)
Microchip
Vaccines
Tumor Removal
Dental Cleaning
Orthopedic Surgery
Other
If 'Other' selected, please list below:

If 'Tumor Removal' selected, would you like us to send tumor out for histopathology?
Yes ***Additional Charges will apply
No
**If 'Dental Cleaning' selected, please note that we will try to reach you by telephone if there are any additional diseased teeth that require extraction that were not previously discussed/predicted/diagnosed.
If we are unable to reach you, please select one of the following:
Proceed with the necessary extractions at their additional associated costs
Do not perform further extractions. I understand these teeth need to be addressed at a future date at an additional cost up to and including another anesthetic procedure
ANESTHETIC CONSIDERATIONS: All anesthesia is tailored to each pet's specific needs.
Is your pet currently on any medications? If yes, please list: (required)

When did your pet last receive any medications:

When did your pet last eat? (required)

Is your pet allergic to any medications? If yes, please list: (required)

Does your pet have any health problems? Epilepsy? If yes, please list: (required)

What telephone number can you be REACHED AT TODAY? (required)

PRE-ANESTHETIC BLOODWORK
Advances in anesthesia and surgery have made routine procedures relatively safe with a low percentage of complications. Those problems which can arise are usually due to pre-existing conditions not evident during pre-surgical exams.
For this reason, we require pre-anesthetic bloodwork.
For pets < 7, this bloodwork is $70.04
For pets > 7, we require more extensive bloodwork for a fee of $152.70-$191.44
My pet has already had the required blood work done <30 days
PAIN MANAGEMENT:
At the doctor's discretion, your pet will receive pain medications both in-hospital as well as to go home. If these medications become necessary, there will be an additional charge.
(required)
I authorize and direct Christopher Alvey, DVM, Jonathan Gilvarry, DVM and/or Phillip Thompson, DVM to perform these operations/procedures upon the patient listed above and/or do any therapeutic procedures that their judgement may dictate to be advisable for the patient's well-being. The risks and nature of the operation/procedures have been explained to me and no guarantee has been made as to the result or cure.
(required)
*If fleas are found on your pet, a flea medication will be given, and the fee will appear on your invoice
Comments for the doctor:

Please type your first and last name: (required)

Date: (required)


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