Macon Road Veterinary Clinic, P.C.

4398 Macon Road
Columbus, GA 31907

(706)563-6101

www.maconroadvet.com

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

 
 

Anesthesia Release Form

Name (required)
First Name (required)
Last Name (required)
E-Mail Address (required) :
Phone (required)
Phone TypePhone Number (required)
Pet's Name (required)

Age

Breed

Sex

Male
Female


Would you like a biopsy?($89.00)

Yes
No


Would you like your pet microchiped today?($54)

Yes
No


Are your pet's vaccinations current?

Yes
No
Don't Know


Did your pet eat or drink this morning?

Yes
No


Is your pet allergic to any drugs that you know of?

Yes
No


If so, which ones?

Would you like your pet to have a dental cleaning this morning?($69.50)

Yes
No


Would you like your pet to have post-operative laser therapy this morning?($10.80)

Yes
No


Laser therapy helps stimulate healing and helps to reduce pain and swelling.
History (check all that apply)
Coughing
Sneezing
Vomiting
Diarrhea
Itching
(For pets under 6 years old)
I authorize Preanesthesia bloodwork (HP/CBC) for my pet today($99.00)
(For Pets over 6 years old)
I understand that all patients over 6 years old are required to have Preanesthesia bloodwork($99.00)

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