Surgical Release Form - Jackson Square Animal Clinic

Day Time Phone Number:

Emergency Phone Number:

Owner Name:

Address:

Pet's Name:

Breed:

Color

I certify that I AM the owner/agent of the above animal(s), and have the authority to execute this consent.

I understand that I am responsible for payment of all above-mentioned procedures and operations in full at the time the animal is discharged, and that my animal may not be released to me until that balance is paid in full.

I understand and consent that dental prophylaxis may require removal of badly diseased teeth in addition to plaque and tartar

Owner/Agent:

Date:

Name:

Date:

Procedure:

Medications (Last Given?):

Vaccinations

K9 Distemper/Parvo

Feline Distemper

1yr 3yr Series Rescue

Kennel Cough

Oral Injectable Rescue

Feline Leukemia

1yr Series Rescue

Rabies

Laboratory

Bloodwork

PSS/CBC Panel/CBC T4 Other

Heartworm Testing

4DX Heartworm only

Felv/FIV/HW Stool/Fecal Test Urinalysis Other

Surgery

Spay (OHE) Neuter Mass/Tumor/Wart Removal

Histopath?

Pain Meds

In House To go Home Doctor's Discretion See Estimate

Dental cleaning Extractions

Other

Heartworm Prev

Apply Here Send Home

Flea Preventive

Apply Here Send Home

Home Again SARG

Special Diet

Clinic Diet:

Canned Dry

Food/Medication Allergies?

Medication Preferences

Pills Liquid Injection (If possible)

Signature of Owner:

Date