Springdale Animal Hospital

2903 West Huntsville Ave. Springdale, AR 72762

479.751.2327 (phone) 479.751.2860 (fax)

Dr. Elizabeth Carender Dr. Christy Booth

Dr. Deborah Overman

General Surgery & Anesthetic Release Form

Name:______

Pet’s Name:______Age: ______

Procedure(s) to be performed: ______

Prior to being anesthetized, a physical exam ($38.00) may be required for your pet. We also require that pets are current on their Rabies Vaccination. ($12.00) Proof will be required upon admission. Please ask if you are unsure if this applies to your pet(s). Payment is due at the time the services are rendered. We also offer Care Credit, a credit card for Veterinary services.

We recommend performing a Pre Surgical Screening (blood work to evaluate your pet) BEFORE using any anesthetic. These tests allow us to see “inside” your pet and make informed decisions about the best way to treat him/her medically. Do we have your permission to perform these OPTIONAL tests?

$55.00 For CBC Serum Chemistry Panel? Yes ___ No ___

We recommend placing an IV catheter and administering fluids for all animals undergoing any anesthetic procedure. This will allow us to maintain your pet’s blood pressure and liver/kidney function. It is also necessary in emergency situations in which fluids or medications are needed quickly.

$38.75 to place a catheter and run fluids? Yes ___ No ___

Your dog may receive Recuvyra as part of his/her pain control protocol. It is a topical form of fentanyl (an opioid pain medication) that lasts for 3 days. It is applied to the skin on the back, between the shoulder blades. While this is a safe product, you should avoid contact with the application site for 3 days.

Please initial to show that you have read or been informed about Recuvyura ______

Have you withheld Food and Water for at least 12 hours? Yes ___ No ___

Is your pet on any medication that we need to know about?

If yes, Please explain:______

When was flea and tick prevention last given and what type? ______

While your pet is anesthetized, would you like us to perform any of the following procedures?

Please mark if yes:

_____Apply Fluoride treatment to healthy teeth ($7.50)

_____Microchip Placement and lifetime registration– required for Springdale/Fayetteville residents ($30.00)

_____Pedicure (No Charge)

_____Other: ______

Signature:______Date:______

Phone Number:______

Our kennel has a “NO FLEAS OR TICKS” policy. If your pet is examined and found to have fleas or ticks, he/she will be treated at an additional cost. Ranging from $4.50-$18.50 per dose, per pet.