St. Joseph Animal Wellness Clinic, PC

2610 N Trail Ln
Saint Joseph, MI 49085


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)
$184 Senior Pre-Surgical Bloodwork ($75 Discount)
$137 Youth Pre-Surgical Bloodwork ($21 Discount)
AVID Microchip Implantation ($88 including registration)

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)
If scheduled for a spay, has your pet been in heat?
If yes when?

Is your pet on any oral medications? (required)
List medications if any:

Has your pet ever had seizures? (required)
Digital Signature (Full Name) (required)

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