Surgery Release Form in Belle Vernon, PA - Valley Veterinary Service

Owner*

First Last

Patient's Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Breed*

Canine
Feline

Phone*

Email*

Who can be reached during the day of the surgery?*

Name	Number	Cell / Work / Phone

Please check desired procedures

Spay (Female
Neuter (Male)
Declaw
Tumorectomy/Biopsy
Cystotomy
Exploratory
Dewclaw Removal
Microchip
Ear Cleaning

I hereby authorize Valley Veterinary Service, Inc. to perform such diagnostic, therapeutic and surgical procedures as are, in their opinion, necessary and advisable for treatment and maintenance of my pet’s health and well-being. I do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give Valley Veterinary Service, Inc. full and complete authority to perform the surgical procedure described above.

The nature of such services has been described to me to my satisfaction and, while I expect all procedures to be done to the best of the abilities of the professional staff, I realize that NO guarantee or warranty can ethically or professionally be made regarding the results or cure.

A geriatric blood profile is REQUIRED for geriatric patients or patients with health problems before undergoing anesthesia

Pre-anesthetic bloodwork for healthy patients under 8 years of age*

Yes
No

Date*

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL SERVICES RENDERED.*

Type Name

ANY patient that is hospitalized is required to have a current rabies and distemper vaccine. If there is no proof of vaccine upon admission, your pet will be vaccinated while hospitalized and charged accordingly!

An e-collar or a recovery shirt will be fitted for your pet if they show signs of licking and/or chewing at their incision.