Cole Veterinary Hospital at Legends Ranch

2757 Rayford Road Suite #A
Spring, TX 77386

(281)465-0880

www.colevet.com

Surgery Release Form

Name
First Name
Last Name
Address
Street Address
City
,
State / Province
Zip / Postal Code
Phone
Phone TypePhone Number
Pet Name

Was your pet fasted from food 12 hours prior to surgery? (Yes / No)

Breed

Male / Female

Age

Color

Weight (in lbs)

Surgical Procedure(s):

Owner Consent
I declare that I am the owner/owner's agent of the described pet and am fully able to make decisions for this animal. I assume and accept total responsibility, including financial responsibility for all services rendered by Cole Veterinary Hospital, its staff or employees in the treatment of my pet, and agree to pay for such services when the services are performed or when my pet is picked up. I will not hold Cole Veterinary Hospital responsible for unforeseen injury, escape, or death of my pet while in our care. I realize anytime anesthesia is indicated, there are potential risks including possibility of death. I am aware of these risks and authorize Cole Veterinary Hospital to proceed with the agreed upon procedure(s). Cole Veterinary Hospital requires pets to be free of external and internal parasites. If a pet is found with parasites, the parasite medication(s) will be given at the owner's expense. Owner Consent: In case of a life threatening emergency where an owner cannot be reached, Cole Veterinary Hospital will perform any necessary life saving services at the owner's expense.
Authorization
I authorize any services the doctor deems necessary for the best care for my pet if someone cannot be reached.
I authorize the services (required)

Yes
No


Do not administer any medical treatment until specific authorization is given

Yes
NO


Please list any medications your pet has received in the last 24 hours:

*Please list any known prior drug or anesthesia complications:

While under anesthesia, would you like any of the following performed at an additional charge?:
Nail Trim
Microchip
Ear Cleaning
Anal gland expression
Vaccines
NONE
Date :
By checking yes on this box I agree to all the terms and condition on this form (required)

Yes
No


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Preferred Pick Up Time (Between 3-5 pm) :

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