(865) 523-6886
Surgical/Anesthetic Release Form

  • Please initial any additional services you would like to have performed at this time to reduce the need for future visits and minimize discomfort for your pet. The cost for these services is not included in the cost of the procedure. Please ask a CRS for prices.
  • Pre-Anesthetic Bloodwork

  • Many health problems cannot be identified by a physical exam, so we strongly recommend all pets receive a preanesthetic blood screen to help determine the presence of internal illness that may cause complications with anesthesia. This screening does not guarantee the absence of potential complications, but does greatly reduce the risk of complications and helps identify health conditions that may require medical treatment in the future. The cost of the preanesthetic panel and CBC is $66. Please initial the box indicating whether you accept or decline this screening for this pet today.
  • Surgical Release

  • I, the undersigned, do hereby certify that I am the owner or authorized agent of the animal described above. I give CVH full and complete authority to perform the medical and/or surgical procedure and associated anesthesia stated below as well as any procedures deemed necessary by the doctor that are in the best interest of my pet. I do release CVH from any and all liability for so performing the surgical procedures.
  • Intravenous Fluids

  • Your veterinarian may also strongly recommend that your pet receive fluid therapy. Although we choose anesthetics we feel to be the safest in each case, IV fluids help improve the safety of certain surgical events. In addition, IV fluids can help speed a pet's recovery from anesthesia and help our pain control medications work more effectively.
  • Statement of Commitment

  • The staff of Central Veterinary Hospital (CVH) assures you that we will use our best judgment in caring for your pet. This judgment is based on experience, the physical exam of your pet, and any laboratory analysis you authorize.
  • Payment Policy

  • I agree to pay, in full, for services rendered including those deemed necessary for medical or surgical complications or otherwise unforseen circumstances. I understand that any provided estimate of fees for presently planned procedures is only a best approximation, and the the final bill may be less or greater than this estimated amount. Should I fail to pay for any services provided, I will be responsible for all service charges and collection fees.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.