Surgical Release Form

Your pet is scheduled for an anesthetic procedure. In order to recognize any underlying abnormalities your pet may have, and to determine any increase in anesthetic risk, we recommend a pre-anesthetic blood profile be completed. This complete blood cell count (CBC) and chemistry panel will check for signs of infection/inflammation, anemia, platelet counts, blood glucose, kidney function and liver function. In some cases, especially in older patients, electrolytes are screened to check for imbalances that can cause heart arrythmias, prolonged healing and other health issues.

Testing can significantly reduce the medical risks associated with anesthesia. A healthy-appearing pet may be hiding symptoms of disease (a patient can lose up to 75% of kidney function before showing any visible signs of illness). Testing helps us evaluate your pet’s health for selection of an appropriate anesthetic protocol to minimize the risks related to anesthesia. If pre-anesthetic results are within normal ranges, we can proceed with confidence that anesthetic risk has been minimized. However, if pre-anesthetic results are not within the normal ranges, we may recommend additional diagnostics, alter the anesthetic protocol or reschedule the anesthetic procedure in an effort to safeguard your pet’s health and reduce the risk of potential complications. Additionally, these tests provide baseline levels for your pet and become part of his/her medical record for future reference.

A partial list of complications associated with dental procedures includes infection, excessive bleeding, fracture of the jaw with extractions, suture reaction, fistula formation, root tip fracture, and non-healing gingival tissue. In some cases, with multiple extractions or extractions of one or more of the canine teeth or incisors, increased drooling and protrusion of the tongue may occur. These signs usually resolve with time as the pet becomes accustomed to the change in the dental structure.

Should, based on the medical judgment of a licensed Doctor of Veterinary Medicine, my pet named require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, emergency drugs, or other heroic interventions, I request or decline that the doctor(s) at Hales Corners Veterinary Clinic pursue such medical care as indicated below.

I have been informed by Hales Corners Veterinary Clinic that less than 5% of animals that require CPR will survive to be discharged from the hospital. I understand that despite the best efforts of the veterinarians and staff at Hales Corners Veterinary Clinic, CPR may not save my pet’s life. I also understand that even if CPR is successful, my pet may never regain his/her normal mental and physical health and, thus, may leave him/her as an invalid.

Regardless of whether I consent or decline to have CPR performed on my pet, in consideration for following my directive, I hereby waive, release and discharge any and all claims for damages, including, but not limited to claims for death, injury or property damage, whether or not resulting from the negligence, gross negligence, misconduct or other acts Hales Corners Veterinary Clinic, its veterinarians and staff, that I may have individually or on behalf of my pet, or that may subsequently accrue, as a result of honoring this directive, and I declare that any such veterinarian, staff and the Hales Corners Veterinary Clinic is acting in accordance with my directions. This is intended to be an advance release of legal liability, even if negligence or other misconduct occurs.

I, the undersigned owner or owner’s agent, of the pet identified above, certify that I am over 18 years of age and hereby authorize the doctor(s) at Hales Corners Veterinary Clinic to perform the above anesthetic and surgical procedure(s) for my pet. I understand that some risk always exists with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. While I accept that all procedures will be done to the best of the abilities of the staff at Hales Corners Veterinary Clinic, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I agree to assume financial responsibility for the full balance of the services on a cash, credit card, or check basis at the time my pet is discharged from the hospital today.

Owners will receive updated cost estimates whenever additional testing or precautions are necessary at the owner’s request.  Hales Corners Veterinary Clinic will also make every effort to contact owner prior to determining or performing any additional treatment that changes the original estimates, outside of emergency care which will be deemed necessary by the veterinarian.

I understand that Hales Corners Veterinary Clinic will make every reasonable effort to contact me prior to performing additional procedures and that if I cannot be reached an additional anesthetic procedure may be required in the future to avoid keeping my pet under anesthesia longer than necessary.

Please provide the best contact information to call for any questions or updates during or after the procedure. Please ensure that listed contact information will be available throughout the planned procedure day. By listing any contact below other than yourself as the primary pet owner, you are agreeing that they are at least 18 years of age and are allowed to make decisions about patient care on the planned procedure day.