Surgery Release Form

Owner’s Name

Pet’s Name

Emergency Phone Number

Procedure to be preformed:

Required Procedures

Initial: Post surgical pain medication is required for all surgical procedures.

Canines will be sent home with oral medication, cost is determined by weight, usually $25-$30
Felines will receive a pain injection that will last for 3 days. Cost is $35

Initial: Extraction of retained baby teeth at the cost of $15 per tooth.

Initial: Extraction of diseased adult teeth at a minimum cost of $40 per tooth

Optional Procedures (Check box if requested)

Initial $77.00 Dr. Mark Sprayberry recommends bloodwork before your pet undergoes anesthesia. If the results are with normal ranges, then we can proceed with confidence, knowing anesthetic risk is minimized. However, if the results are not within normal ranges, then we can modify the anesthetic procedures to fit your pet’s needs, or postpone the procedure

Please specify?

DECLINED BLOODWORK

Microchip Implant $49.00

Deep Nail Trip & Cautery of the Quicks - $60 plus antibiotics - While under anesthesia we trim every pet's nails at no charge. However, we can painlessly cut your dog's nails very short and cauterize the nail bed. This procedure is especially helpful for dogs that are fearful of nail trims.

Pre Screening Hip Dysplasia Radiographs - $65.00 (discounted from $160.00). This procedure is for our large breed patients. While under anesthesia, we can check for early signs of hip dysplasia with radiographs.

I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above; that I hereby give Dr. Mark Sprayberry, his agents, servants, or representatives full and complete authority to perform the surgical procedure said above, and to perform any other procedure that, at their discretion, may be useful to promote the health of the above-described pet, and I do hereby and by the presents forever release the said doctor, their agents, servants, and representatives from any and all liabilities arising from said surgery on said animal. I understand that in all procedures performed there is a certain amount of risk involved and that I fully accept such risks.

It is further understood that all charges shall be paid in full upon release from hospital. I hereby state that my animal has been fasted for at least eight hours prior to surgery. I also understand that I will be charged for a flea treatment if it is found that my pet has fleas.

Signature

Date