Please note: We will be closed on Tuesday, December 24th and Wednesday, December 25th for Christmas!

New Hours

Mon, Tues, Thurs, and Fri 7:30am – 6:00pm
Wed and Sat 8:00am-12:00pm
Sun closed

Online Form

Surgical Authorization and Release Form Town and Country Veterinary Hospital

Save time during your next appointment! Complete your required forms online from any device at any time before your visit.

Get Started

Surgical Authorization and 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.

Download Form

Town and Country Veterinary Hospital and staff will use all reasonable precaution against injury, escape or death to pet. I understand that all surgery with anesthesia involves some minimal risk to my pet. I will not hold town and country Veterinary hospital Responsible in connection with the risks associated with these surgical procedures. *

I have read and understand.

Date *

Owner/Agent *

Email *

Best Phone number *

My pet is here for sedation/anesthesia/surgery. I understand that adequate kidney and liver function is essential to the breakdown and removal of common anesthetic agents from the body. A pre-anesthetic panel consisting of the following tests are recommended by the Veterinarian for all patients to ensure the anesthetic agents are moved from my pet's system: *

I have read and understand.

Kidney Function test (blood urea nitrogen)

Liver Function test (ALT)

The combined cost for this pre-anesthetic panel is $38.50 (Optional) *

I do request that these tests be performed
I do not request these tests be performed

E-Collar

An Elizabethan collar (also known as an E-collar or the cone of shame) are plastic or fabric hoods or cones placed around the head to prevent an animal from licking at a surgery site, wound, or dressing. *

Plastic: Clear/see-through, custom sizing for neck and length Cost: $23.00-$32.50
No- I have an e-collar already and I will bring it to the discharge appointment
Per the Doctor, this procedure doesn’t require an e-collar

Multi-Parameter Surgical Monitor Offered

During your pet's surgical procedure, we always use equipment which monitors their pulse rate, respiratory rate and blood oxygen concentrations for safety at no charge. We now offer a multi-parameter surgical monitor for even MORE safety during the surgical procedure. The M-P monitor now allows us to monitor the heart itself with electrocardiogram (ECG), heart arrhythmia warnings, blood pressure monitoring, heart rate, respiratory rate, oxygen concentration and core temperature monitoring. This additional safety monitoring is (OPTIONAL). The cost is $45.00 *

I do wish to have the additional monitoring
I do not wish to have the additional monitoring

Pain medication for all NON-Orthopedic Surgeries

Prices Vary by weight:

Cats 5-15lbs will range from $10.60-$12.00 additional

Dogs 2-75lbs will range from $10.60-$20.10 additional

For animals larger than this please ask for an exact quote.

Pain medication is optional, but HIGHLY RECOMMENED. It will be administered DURING surgery to aide in keeping your pet comfortable during the recovery process and their first night of recovery. Additional medication is available upon request. *

I do request pain medication for my pet
I do not wish to have pain medication for my pet

Therapeutic Laser Therapy

We now offer medical laser therapy for your pet immediately after surgery to help reduce any swelling and local pain around the incision site. The charge for this procedure is an additional $9.70 *

I do request medical laser therapy for my pet
I do not request medical laser therapy

****NOT AVAILABLE FOR MASS REMOVAL SURGERIES OR EYE SURGERIES*****

Propofol Pre-Anesthetic Agent

While our general anesthesia is very safe, propofol can be added for additional safety especially HIGH RISK and Cardiac patients. It is Required for patients 7 years and older. Cost is $32.50 *

I do want propofol
I do not want propofol

Microchip

Would you like us to microchip your pet? *

I authorize for my pet to be microchipped
No, I would like to decline microchipping at this time
My pet is already Microchipped.

Life saving measures (CPR)

In the event of Cardiac Arrest during hospitalization (hear or breathing stops): *

I request emergency and lifesaving procedures (including Cardiopulmonary resuscitation) be performed immediately on my pet. I understand I will not be contacted prior to these actions and give permission for the doctors and staff at Town and Country Veterinary hospital to take reasonable measures in treating my pet. I accept all additional charges that are incurred as a result of action. I understand Initiating CPR does not guarantee survival.
DO NOT resuscitate (DNR). I understand Town and Country Veterinary Hospital will do everything possible to keep my pet stable during hospitalization and/or the procedure. If my pet has unstable vital signs, our staff will perform necessary steps to stabilize him/her. However, if my pet suffers cardiopulmonary arrest (hear stops, breathing stops), the staff will NOT attempt CPR. I understand this will lead to death.

Financial Options

I authorize Town and Country Veterinary Hospital to perform the procedures(s) outlined in the associate treatment plan on my pet. I understand the itemized treatment plan is a good-faith representation of what will be performed during this procedure. If Town and Country Veterinary Hospital encounters any NON-EMERGENCY, unexpected complications, or medical conditions that require the treatment plan to be altered, every effort will be made to contact me as these issues arise. In the case the hospital staff is unable to contact me, Town and Country Veterinary Hospital will follow my instructions as outlined below. *

I have read and understand

If unexpected complications or medical problems arise during my pet’s hospitalization and I cannot be reached at my contact phone number: *

DO NOT perform any treatment or diagnostic testing on my pet that was not outlined in the treatment plan presented to me today. I understand that in some situations, this decision may negatively impact my pet’s health, and I take responsibility for delaying care. In making this decision, the doctors and staff at Town and Country Veterinary hospital will not be held liable or responsible for the results of my decision. I understand that should I choose to pursue these recommendations at a later time, follow-up charges will apply in addition to today. Recommendations for unexpected additional services may change as my pet’s clinical status changes.
Perform additional treatments/services deemed medically necessary by the attending doctor as detailed below. I understand these services were not listed on the treatment plan presented to me and thus additional charges are my responsibility (due at discharge). Town and Country Veterinary Hospital staff will make every attempt to contact me at the numbers I provided before proceeding with the additional services. Treatments/diagnostics that are purely elective, or that will not benefit my pet's immediate health will not be performed without my permission.

I am over 18 and understand that I accept that all procedures will be performed to the best of the abilities of the staff at the hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow-up radiographs, re-check physical exam and additional surgery due to post-op complication. These are more likely to occur when there is a failure to comply with the aftercare instructions. I have been provided an estimated cost for the procedure(s) listed above. I assume financial responsibility for the recommended services and will provide payment in full at the time my pet is discharged from Town and Country Veterinary Hospital. I have read and fully understand the terms and conditions set forth above. *

I have read and agree.

Owner Name *

Owner Signature *

Clear Signature

Todays Date *

Pre-surgical Questionnaire

Best phone number to reach you today: *

How is your pet’s energy level? Describe their normal activity or routine. How do they tolerate exercise? *

Normal
Moderate
Sudden changed

Is your pet allergic to any medications, including anesthesia: *

Have you given your pets any medications or supplements in the past week? *

What time did your pet last eat and/or drink? *

Do you have any questions or concerns you would like to speak to a staff member about? (Please explain)

Please make sure to check out the Surgery Handout by clicking here.