St. Joseph Animal Wellness Clinic, PC

2610 N Trail Ln
Saint Joseph, MI 49085

(269)429-6966

www.sjvet.com

Surgery Release Form

Name (required)
First Name (required)
Last Name (required)
Patient Name (required)

Phone (required)
Phone TypePhone Number (required)
I am authorizing the following procedures: (required)
Surgical Sterilization
Dental Cleaning with Extractions (If deemed medically necessary by the Veterinarian.)
Other (Enter Below)
Other Procedure(s):

I would like the following additional elective procedures performed.
(Pre-Surgical Bloodwork)
$135 Senior Pre-Surgical Bloodwork ($75 Discount)
$105 Youth Pre-Surgical Bloodwork ($25 Discount)
Microchip Implantation

Nail trims are complimentary.

Pain medication will be utilized for every surgical procedure.

Furthermore, I understand that during the performance of the procedure(s) that I have authorized, unforeseen conditions may arise, therefore, I hereby consent to and authorize the performance of such procedures as are necessary in the exercise of the Veterinarians professional judgment. I also do hereby acknowledge that I understand that there are no guarantees either expressed or implied that the procedures authorized will be without complications from unexpected events beyond the Veterinarians and Hospitals control.
Is your pet potentially pregnant? (required)
Yes
No
Is your pet on any oral medications? (required)
Yes
No
List medications if any:

Has your pet ever had seizures? (required)
Yes
No
Digital Signature (Full Name) (required)


Verify the reCAPTCHA: