Surgical Release Form - Erlanger Veterinary Hospital

Today's Date *

How would you like to be notified when surgery has been completed? *

Phone Call
Text Message
Email

***MUST BE ACCESSIBLE BY PHONE OR E-MAIL FROM 9:00 – 4:00 TODAY!!!***

Phone number where you can be reached TODAY *

Alternate phone number

I hereby authorize Erlanger Veterinary Hospital and its designated associates, technicians or assistants to treat, anesthetize, prescribe medications for, and perform specified diagnostic tests or surgery on my pet, *

I understand the risks associated with these procedure(s) *

and know that all reasonable precautions will be taken against injury, escape, or destruction of my animal and will not hold Erlanger Veterinary Hospital responsible in event of such.

In the event that hospitalization is recommended, I understand my pet will not be monitored by the veterinary staff outside of normal business hours. I also acknowledge that the option to transfer my pet to an emergency care facility for continuous monitoring was discussed as an alternative option. *

I have read and understand.

If emergency treatment is required and I cannot be reached, I authorize Erlanger Veterinary Hospital to perform such procedures as are necessary to preserve the life of the patient until I can be contacted. *

Yes
No

Please Initial *

Please list any medications your pet has received in the past 24 hours and the times they were given. *

Deposit Policy: It is the policy of our hospital to require a minimum deposit of 50% of the estimate. Please leave this payment with the receptionist when admitting your pet into the hospital.

Additional Options

Microchip Implant & Registration
Refill Heartworm, Flea & Tick Prevention

Please select which type of heartworm, flea & tick prevention

Our hospital is a "Flea Free Zone" . All pets All pets will be checked for fleas upon admission. If we find live fleas on your pet, they will be treated at an additional cost.

I am the owner or authorized agent of the owner of the pet presented for care. I accept financial responsibility for treatment of the above-named patient and understand that payment in full is due upon release of my pet from the hospital or when service is otherwise terminated. I certify that I have read, fully understand, and agree to this authorization. *

I have read, understand, and agree

Owner Name *

First

Last

Signature of Owner or Authorized Agent *

Clear Signature

Cell Phone # (for Text Alert Only)

E-mail Address (for E-Mail alert Only) *