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Surgical Release Form

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Online Forms

Surgical Release Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 985-847-0591 for a faster response.

Owner's Name *

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Patient's Name *

Breed *

Sex *

Age *

I, the undersigned owner or authorized agent thereof, give consent for the procedure(s) to be performed on the above patient *

I agree

Procedure Name *

I have been informed by the staff of Veterinary Medical Center about the risks involved in the use of anesthesia and/or surgical procedures. I authorize Jeffrey V. Perret, DVM/ Jeanne Richardson, DVM to perform the procedures described to me and understand should any other procedure be needed during the time my pet is under their care, I will be contacted. I understand that I will not hold or any of Veterinary Medical’s staff members responsible for any complications/death of my pet while hospitalized and during the anesthetic/surgical procedure, in the absence of gross negligence. *

I have read and understand

I agree to pay, in full, for services rendered, including those deemed necessary for medical or surgical complications or unforeseen circumstances. Any estimates or charges for the planned procedures are only approximations, and the final bill may be greater or less than these amounts. *

I have read and understand

All Services Must Be Paid For When Is Released. Some Procedures Require A Deposit Be Made Before Surgery.

Please send home pain medication (optional, additional fee) *

Please specify if there are any procedures you would like done while your pet is under our care

Date *

Online Forms

Online Forms

Surgical Release Form

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