Surgical / Anesthesia Release Form
By completing this form, I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute this consent.
I hereby give Dr. Glass, and any authorized agents, staff, or representatives consent and authority to perform the following procedures or operations:
I authorize the use of appropriate anesthesia and pain relief medication as needed before or after the procedure. I have been informed that there are risks associated with the use of any medication.
I understand that hospital support personnel will be used as deemed necessary by the veterinarian.
For all pets we highly recommend a Health Profile with a Complete Blood Count and Differential (HP/CBC). This will assure us that your pet does not have any underlying medical problems that will adversely affect your pet while under anesthesia. For all pets over 6 years old an HP/CBC is required. The cost is $94.00